Case Manager RN - Remote

Highmark Health•PA, Working at Home - Pennsylvania, PA

1d•$72,700 - $116,600•Remote

About The Position

The Case Manager RN provides comprehensive case management services to members to support quality, cost-effective care and optimal health outcomes. The role assesses member needs and available resources, develops and implements individualized care plans, coordinates services, monitors progress, and helps contain health care costs by detecting, resolving, and preventing improper utilization of member benefits. The position manages a caseload of members with moderately complex health needs and collaborates with members, physicians, providers, and other health care team members. It serves as an advocate and liaison for members, using communication and available resources to promote quality, cost-effective outcomes within contract benefits. The role also ensures documentation and activities comply with business processes, company policies, regulations, and accreditation standards, and identifies opportunities for cost savings, quality improvement, and workflow efficiency.

Requirements

High school diploma or GED.
Three years of experience in any combination of clinical, case/utilization management, disease condition management, provider operations, and/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 six months of employment.
Strong assessment and care planning skills.
Ability to work independently and as part of a team.
Proficiency with Microsoft applications, case management software, and electronic health records.
Understanding of health care systems and case management principles.

Nice To Haves

Bachelor’s degree in Nursing.
Experience working with the health care needs of diverse populations.
Experience demonstrating 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 health care providers, with guidance from senior staff.
Implement and coordinate care plans to support 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 for and liaise on behalf of members by assessing, planning, implementing, coordinating, monitoring, and evaluating care options and services.
Collaborate and communicate professionally with physicians, providers, co-workers, and other health care team members to carry out established care plans.
Document activities and ensure compliance 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.