Care Manager RN - UM (Full-Time) Weekends (Remote)

Highmark Health; Boise (ID); A distancia; USD 68.000 - 106.000; Jornada completa

Descripción de la vacante

Highmark Inc. is seeking a full-time Registered Nurse for a remote care management role requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

You will implement utilization management strategies, review care plans, educate providers and members, and analyze data to improve performance and satisfaction. The ideal candidate has 3 years of clinical experience, RN licensure (PA or multi-state via eNLC), and may hold certifications in Utilization Management or related

Formación

• 3 years of related, progressive clinical experience in the area of specialization.
• Experience in a clinical setting.
• Current PA RN licensure or multi-state licensure via eNLC.

Responsabilidades

• Implement care management review processes consistent with standards and guidelines.
• Ensure compliance with state and federal laws.
• Perform care management reviews using established criteria and policies.
• Promote quality and efficiency in care management services.
• Protect member privacy within legal requirements.
• Identify and refer members to Health Coaching/case management when appropriate.
• Collaborate to streamline processes and build provider network relations.
• Educate providers and facilities to improve processes and outcomes.
• Develop and sustain positive relationships with internal and external customers.
• Use outcomes data to enhance care management services.
• Perform other duties as assigned.

Conocimientos

Regulatory compliance

Multi-tasking

Communication skills

Data analysis

Team player

Prioritization

Computer skills

Educación

Bachelor’s Degree in Nursing

Descripción del empleo

Company

Highmark Inc.

Job Description

JOB SUMMARY

This is a full-time REMOTE position requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

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

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

• 3 years RN experience
• RN Case Management, Care Management
• Experience in UM/CM/QA/Managed Care
• Experience with acute inpatient and post-acute
• Experience with skilled nursing, inpatient Rehab

LICENSES AND CERTIFICATIONS

Required

• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). 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

$68,400.00

Pay Range Maximum

$105,900.00

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.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice (https://dokumfe7mps0i.cloudfront.net/oms/4391/document/2026/1/doclib_458575_QLVK9_1769448333304228022_1769448333396/1769448333396.pdf)