Case Manager RN - Remote

Highmark Health•Washington, NV

4d•$72,700 - $116,600•Remote

About The Position

This role provides comprehensive case management services to members to support quality, cost-effective care and optimal health outcomes. The Case Manager assesses member needs and available resources, develops and implements individualized care plans, coordinates appropriate services, and monitors member progress. The role also helps contain healthcare costs by detecting, resolving, and preventing improper utilization of member benefits. The position manages a caseload of members with moderately complex health needs and serves as an advocate and liaison to address each member’s healthcare needs. The Case Manager collaborates with members, physicians, providers, and other healthcare team members, using available resources and contract benefits to promote effective outcomes. Activities must be documented and performed in accordance with business processes, company policies, regulatory requirements, accreditation standards, privacy requirements, and information-security policies. The position is office-based, but a 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 license, 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.
Experience demonstrating an 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 as applicable.
Implement and coordinate care plans to ensure 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 serve as a liaison to meet members’ individual healthcare needs through assessment, planning, implementation, coordination, monitoring, and evaluation of options and services.
Use communication and available resources to promote quality, cost-effective outcomes in accordance with available contract benefits.
Collaborate and communicate professionally with physicians, providers, coworkers, and other healthcare team members to carry out established care plans.
Document activities and comply with 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.