Medical Case Manager - PDN/Private Duty Nursing (Delaware)

Highmark Health•DE, Working at Home - Delaware, DE

5d•$72,700 - $116,600

About The Position

This is a full-time position requiring frequent travel within the assigned territory in Delaware. The Medical Case Manager provides comprehensive case management services to members, supporting quality, cost-effective care and optimal health outcomes. The role assesses member needs, develops and implements care plans, coordinates services, and monitors progress. It also helps contain healthcare costs by detecting, resolving, and preventing improper use of member benefits. The Case Manager manages members with moderately complex health needs and works with members, physicians, other healthcare providers, and the broader healthcare team. The position advocates for members by assessing, planning, coordinating, monitoring, and evaluating care options and services in line with available contract benefits. Activities must be documented and carried out in accordance with company processes, policies, regulatory requirements, and accreditation standards.

Requirements

At least 3 years of experience in any combination of clinical, case/utilization management, disease condition management, provider operations, or health insurance experience, with RN licensure or a master’s degree; alternatively, 5 years of experience with a bachelor’s degree in Social Work.
Bachelor’s degree in nursing, RN licensure, or a master’s degree in Social Work, Counseling, or a related field; alternatively, a bachelor’s degree in Social Work.
One of the required credentials: applicable state Licensed Social Worker (LSW), Licensed Professional Counselor (LPC), Licensed Bachelors Social Worker (LBSW), Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), Licensed Graduate Social Worker (LGSW), or Licensed Certified Social Worker (LCSW); or current state RN licensure or current multistate licensure through the enhanced Nurse Licensure Compact (eNLC). Incumbents in the role before January 1, 2025, who are not currently licensed must obtain licensure by December 31, 2027.
Strong assessment and care-planning skills.
Ability to work independently and as part of a team.
Proficiency with Microsoft Office, case management software, and electronic health records.
Understanding of healthcare systems and case management principles.

Nice To Haves

Pediatric experience.
Medicaid managed care and/or Medicare experience.
Experience working with the healthcare needs of diverse populations.
Understanding of the importance of cultural competency when addressing targeted populations.
Bilingual English/Spanish skills.
Certified Case Manager (CCM).

Responsibilities

Manage a caseload of members with moderate-complexity health needs.
Assess members’ health status, needs, and available resources.
Develop individualized care plans with members, physicians, and other healthcare providers, with minimal guidance.
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 for and liaise on behalf of members by assessing, planning, implementing, coordinating, monitoring, and evaluating care options and services.
Collaborate and communicate clearly and professionally with physicians, providers, coworkers, and other healthcare team members to carry out care plans.
Document activities and ensure compliance with business processes, company policies, regulatory requirements, and accreditation standards.
Identify potential cost savings, quality improvements, and workflow efficiencies.
Perform other duties as assigned or requested.