Care Manager RN - (Remote)

Highmark Health

75d • $50,200 - $91,200

About The Position

This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

Requirements

• 3 years of related, progressive clinical experience in the area of specialization.
• Experience in a clinical setting.
• Current RN state licensure required.
• Additional specific state licensure(s) may be required depending on where clinical care is being provided.

Nice To Haves

• Bachelor’s Degree in Nursing.
• Experience in UM/CM/QA/Managed Care.
• Certification in utilization management or a related field.

Responsibilities

• Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.
• Function in accordance with applicable state, federal laws and regulatory compliance.
• Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
• Promote quality and efficiency in the delivery of care management services.
• Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws.
• Practice within the scope of ethical principles.
• Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
• Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes.
• Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
• Develop and sustain positive working relationships with internal and external customers.
• Utilize outcomes data to improve ongoing care management services.
• Other duties as assigned or requested.

Benefits

• Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions.
• Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities.

What This Job Offers

• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees