Care Manager RN - (Remote)

Highmark; West Virginia; Remote; USD 50,000 - 92,000; Full time

Job summary

A leading health insurance provider is seeking a Care Manager RN for a remote role. This position involves implementing utilization management strategies, educating members and providers, and enhancing healthcare outcomes through data analysis. The ideal candidate will have a Bachelor’s degree in Nursing and relevant clinical experience. Join a dedicated team focused on improving patient satisfaction and performance.

Qualifications

• 3 years of related clinical experience required.
• Current RN state licensure is a must.

Responsibilities

• Implement care management review processes.
• Educate providers and members on care options.
• Utilize outcomes data to improve services.

Skills

Excellent written and verbal communication skills

Ability to analyze data

Multi-tasking

Strong analytical skills

Education

Bachelor’s Degree in Nursing

Job description

Join to apply for the Care Manager RN - (Remote) role at Highmark

Join to apply for the Care Manager RN - (Remote) role at Highmark

Get AI-powered advice on this job and more exclusive features.

JOB SUMMARY

This job implements effective utilization management strategies including review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

Company

Highmark Inc.

Job Description

JOB SUMMARY

This job implements effective utilization management strategies including review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

ESSENTIAL RESPONSIBILITIES

• Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.
• Function in accordance with applicable state, federal laws and regulatory compliance.
• Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
• Promote quality and efficiency in the delivery of care management services.
• Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws.
• Practice within the scope of ethical principles.
• Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
• Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes. Is familiar with the various care options and provider resources available to the member.
• Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
• Develop and sustain positive working relationships with internal and external customers.
• Utilize outcomes data to improve ongoing care management services.
• Other duties as assigned or requested
  
  

EDUCATION

Required

• None
  
  

Substitutions

• None
  
  

Preferred

• Bachelor’s Degree in Nursing
  
  

EXPERIENCE

Required

• 3 years of related, progressive clinical experience in the area of specialization
• Experience in a clinical setting
  
  

Preferred

• Experience in UM/CM/QA/Managed Care
  
  

LICENSES AND CERTIFICATIONS

Required

• Current RN state licensure required. Additional specific state licensure(s) may be required depending on where clinical care is being provided.
  
  

Preferred

• Certification in utilization management or a related field
  
  

SKILLS

• Working knowledge of pertinent regulatory and compliance guidelines and medical policies
• Ability to multi task and perform in a fast paced and often intense environment
• Excellent written and verbal communication skills
• Ability to analyze data, measure outcomes, and develop action plans
• Be enthusiastic, innovative, and flexible
• Be a team player who possesses strong analytical and organizational skills
• Demonstrated ability to prioritize work demands and meet deadlines
• Excellent computer and software knowledge and skills
  
  

Languages (Other Than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches/trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (sales employees)

Does Not Apply

Physical work site required

Yes

Lifting up to 10 pounds

Constantly

Lifting 10 to 25 pounds

Occasionally

Lifting 25 to 50 pounds

Rarely, Occasionally

Disclaimer The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum

$50,200.00

Pay Range Maximum

$91,200.00

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.

For accommodation requests, please contact HR Services Online at [e-mail]

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Insurance

Referrals increase your chances of interviewing at Highmark by 2x

Get notified about new Nursing Manager jobs in West Virginia, United States.

Morgantown, WV $74,000.00-$138,000.00 1 day ago

NON-COMPACT STATE - PT Remote CCM/RTM Care Management Nurse (CA)

Registered Nurse (RN) - Assisted Living/Skilled Nursing- Pick Your Own Schedule

Registered Nurse (RN) - Assisted Living/Skilled Nursing- Pick Your Own Schedule

Chronic Care Manager (Remote - Compact States)

AMAP - Approved Medication Assistive Personnel- Pick your own shifts! Charleston, WV

Registered Nurse - RN / Step Down Unit - TELE-P

AMAP - Approved Medication Assistive Personnel- Pick your own shifts! Huntington, WV

Intake RN - Call Center Evenings Remote Option

Weston, WV $1,634.47-$1,634.47 2 months ago

Weston, WV $1,634.47-$1,634.47 3 months ago

Charleston, WV $1,634.47-$1,634.47 4 months ago

RN Field Clinical Care Coordinator - Worcester County and surrounding areas, MA

LPN/LVN for Skilled Nursing/Assisted Living Floor Nurse - Pick your own shift!

LPN/LVN for Skilled Nursing/Assisted Living Floor Nurse - Pick your own shift!

Registered Nurse - RN / Progressive Care Unit - TELE-P

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.