Senior Case Manager RN - Transplant RN (Remote)

Highmark Health•Carolina, PA

1d•Remote

About The Position

This role provides comprehensive case management to members with complex health needs, using advanced clinical knowledge to support quality, cost-effective care and optimal health outcomes. The Case Manager assesses members’ health status, needs, and resources; develops and implements individualized care plans; coordinates appropriate services; and monitors progress and intervention effectiveness. The role also helps contain healthcare costs by detecting, resolving, and preventing improper use of member benefits. The incumbent advocates for members and serves as a liaison among members, physicians, providers, and other healthcare professionals. They coordinate care in line with available contract benefits, document activities in accordance with business processes and applicable company, regulatory, and accreditation requirements, and provide clinical guidance and mentorship to lower-level Case Managers. The position may be office-based or remote, with occasional physical work-site attendance and less than 25% travel.

Requirements

At least 5 years in any combination of clinical, case/utilization management, disease condition management, provider operations, and/or health insurance experience.
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.
High school diploma or GED.
Current state RN licensure or current multistate licensure through the enhanced Nurse Licensure Compact (eNLC).
Certified Case Manager (CCM) certification must be obtained within 36 months of hire; incumbents in the role as of August 2026 are exempt.

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 clinical area of expertise, such as OCN, CPN, CPON, CNN, CCTC, or CPHQ.

Responsibilities

Manage a caseload of members with complex health needs requiring 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 coordinate options and services through assessment, planning, implementation, monitoring, and evaluation.
Communicate and collaborate with physicians, providers, co-workers, 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.
Provide guidance and mentorship to lower-level Case Managers and serve as a resource for clinical expertise and problem-solving.
Perform other duties as assigned or requested.