Note: The job is a remote job and is open to candidates in USA. BeVera Solutions, LLC is a rapidly growing public health and professional services company that provides innovative solutions to federal and state agencies. The Case Manager will support member-centered health services through comprehensive care coordination, utilization support, and member advocacy, ensuring timely access to care and compliance with program requirements.
Responsibilities
- Provide individualized case management services tailored to each member’s clinical, social, and administrative needs
- Coordinate medical monitoring, diagnostic services, and treatment for members receiving care through the Nationwide Provider Network (NPN)
- Assist members in navigating the WTCHP care continuum, including understanding benefits, treatment pathways, and required documentation
- Support continuity of care by coordinating among NPN providers, the Third-Party Administrator (TPA), Pharmacy Benefits Manager (PBM), and WTCHP Program staff
- Deliver both standard and intensive case management services in accordance with WTCHP Case Management and Utilization Management Standard Operating Procedures
- Identify barriers to care such as geographic access, provider availability, coordination of benefits, or member adherence, and implement strategies to mitigate those barriers
- Promote efficiency and appropriate utilization of services while supporting high member satisfaction and positive health outcomes
- Encourage and support member self-management of care over time, as clinically appropriate
- Collaborate with NPA utilization management staff to support prior authorization processes related to certified WTC-related conditions
- Review clinical documentation and supporting information to ensure services align with Program coverage requirements
- Monitor trends in utilization and member needs and communicate emerging issues to leadership to inform program improvements
- Serve as an advocate for members by addressing concerns, resolving care coordination issues, and facilitating communication among stakeholders
- Assist members in understanding Program policies, rights, responsibilities, and appeals processes
- Support outreach efforts to re-engage inactive or hard-to-reach members
- Maintain accurate, timely, and compliant case records within the NPA’s secure data and document management systems
- Ensure documentation complies with HIPAA, WTCHP privacy requirements, and National Archives and Records Administration (NARA) digitization standards
- Participate in bidirectional data exchanges with WTCHP and other Program contractors to ensure consistency and accuracy of member information
- Participate in quality assurance activities, audits, and performance monitoring initiatives
- Contribute to continuous improvement efforts by identifying trends, systemic issues, and opportunities to enhance member experience and care coordination
- Complete required training and maintain up-to-date knowledge of WTCHP policies, procedures, and evolving Program requirements
Skills
- Bachelor's degree in Nursing, Social Work, Public Health, Health Administration, or a related field
- Minimum of 3–5 years of experience in healthcare case management, care coordination, or utilization management
- Active clinical licensure (e.g., RN, LCSW, LMSW, or equivalent) preferred for clinical case management roles
- Demonstrated experience working with complex medical populations, chronic conditions, or federally funded health programs
- Strong knowledge of healthcare delivery systems, referral networks, and benefits coordination
- Experience working with geographically dispersed populations and telephonic or remote case management
- Strong interpersonal, communication, and member-engagement skills
- Ability to manage complex cases with empathy, professionalism, and attention to detail
- Excellent organizational and documentation skills
- Proficiency with electronic case management systems and secure data platforms
- Ability to work independently while collaborating effectively within a team-based environment
- Master's degree
- Experience supporting federal health programs or government-funded benefit programs
- Familiarity with utilization management, prior authorization processes, and medical necessity determinations
- Experience working in multidisciplinary environments involving providers, administrators, and government stakeholders
- Cultural competency and experience communicating with diverse populations on sensitive health-related topics
Company Overview
BeVera Solutions provides data science training and consulting. It was founded in 2013, and is headquartered in Atlanta, Georgia, USA, with a workforce of 11-50 employees. Its website is https://www.beverasolutions.com.
