Case Manager RN

Highmark Health•Carolina, PA

3d•Onsite

About The Position

This job provides comprehensive case management services to members, ensuring quality, cost-effective care delivery and promoting optimal health outcomes. The Case Manager assesses member needs, develops and implements care plans, coordinates services, and monitors progress while helping contain healthcare costs through detecting, resolving, and preventing improper utilization of member benefits. The role manages members with moderately complex health needs and works with members, physicians, providers, and other healthcare team members to support access to appropriate services and resources. It advocates for members by assessing, planning, coordinating, monitoring, and evaluating care options in accordance with available contract benefits. Activities must be documented and conducted in compliance with company processes, policies, regulatory requirements, and accreditation standards. This is an office-based position; the physical work site is not required. Travel is listed as 0%–25%.

Requirements

High school diploma or GED.
At least 3 years of experience in any combination of clinical, case/utilization management, disease condition management, provider operations, or health insurance experience.
Current Pennsylvania RN licensure, or current multistate licensure through the enhanced Nurse Licensure Compact (eNLC), or RN licensure in West Virginia, Delaware, or New York. Other RN licenses, if applicable, must be obtained within the first 6 months of employment.
Strong assessment and care-planning skills.
Ability to work independently and as part of a team.
Proficiency with Microsoft suite applications, case management software, and electronic health records.
Understanding of healthcare systems and case management principles.

Nice To Haves

Bachelor’s degree in Nursing.
Experience working with the healthcare needs of diverse populations.
Understanding of the importance of cultural competency in addressing targeted populations.

Responsibilities

Manage a caseload of members with moderate-complexity health needs.
Assess members’ health status, needs, and available resources.
Develop individualized care plans in collaboration with members, physicians, and other healthcare providers, with guidance from senior staff.
Implement and coordinate care plans, ensuring access to appropriate services and resources.
Coordinate referrals to specialists and community resources.
Monitor member progress toward goals and adjust care plans as needed.
Evaluate the effectiveness of interventions and services.
Advocate and act as a liaison to meet members’ individual healthcare needs through assessing, planning, implementing, coordinating, monitoring, and evaluating options and services.
Use communication and available resources to promote quality, cost-effective outcomes in accordance with available contract benefits.
Work collaboratively and communicate clearly and professionally with physicians, providers, coworkers, and other healthcare team members to carry out established plans of care.
Document activities and comply with applicable business process requirements, company policies, regulatory requirements, and accreditation standards.
Identify potential cost savings, quality improvements, and workflow efficiencies.
Perform other duties as assigned or requested.