Senior Case Manager RN - Transplant RN (Remote)

Highmark Health

1d•$79,300 - $127,100•Remote

About The Position

This role provides comprehensive case management for members with complex health needs, applying advanced clinical knowledge to support quality, cost-effective care and optimal health outcomes. The Case Manager assesses member health status, needs, and available resources; develops individualized, complex care plans with members and healthcare providers; coordinates access to appropriate services; monitors progress; and evaluates interventions. The role also helps contain healthcare costs by detecting, resolving, and preventing improper utilization of member benefits. The Case Manager advocates for members and serves as a liaison among them and their care teams. The role requires collaborative, clear, and professional communication with physicians, providers, coworkers, and other healthcare professionals; documentation and compliance with company processes, policies, regulatory requirements, and accreditation standards; and providing mentorship and clinical expertise to lower-level Case Managers. The position is designated office-based or remote, with occasional physical work-site attendance and less than 25% travel required.

Requirements

At least 5 years in any combination of clinical, case/utilization management, disease condition management, provider operations, and/or health insurance experience.
High School diploma or GED.
Current state RN licensure or current multistate licensure through the enhanced Nurse Licensure Compact (eNLC).
Obtain Certified Case Manager (CCM) certification within 36 months of hire; incumbents in the role as of August 2026 are exempt.
Expertise in clinical assessment and care planning.
Strong leadership and mentoring skills.
Excellent negotiation and advocacy skills.
Proficiency with Microsoft suite applications, case management software, and electronic health records.
Strong understanding of healthcare systems and case management principles.

Nice To Haves

Transplant-specific clinical experience.
Experience working with the healthcare needs of diverse populations.
Understanding of the importance of cultural competency in addressing targeted populations.
Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing, or dialectical behavior therapy (DBT).
Bachelor’s degree in Nursing.
Certification in a clinical area of expertise, such as OCN, CPN, CPON, CNN, CCTC, or CPHQ.

Responsibilities

Manage a caseload of members with complex health needs, applying advanced clinical knowledge.
Conduct comprehensive assessments and develop complex care plans.
Assess members’ health status, needs, and available resources.
Develop individualized care plans in collaboration with members, physicians, and other healthcare providers.
Implement and coordinate care plans, ensuring access to appropriate services and resources.
Monitor member progress toward goals and adjust care plans as needed.
Evaluate the effectiveness of interventions and services.
Advocate for members and act as a liaison to meet their individual healthcare needs by 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.
Collaborate and communicate professionally with physicians, providers, coworkers, and other members of the healthcare team to carry out established care plans.
Document activities and comply with applicable business process requirements, company policies, regulatory requirements, and accreditation standards.
Provide guidance and mentorship to lower-level Case Managers.
Serve as a resource for clinical expertise and problem-solving.
Perform other duties as assigned or requested.