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

Highmark Health; Philadelphia (Philadelphia County); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Health is seeking a full-time RN for a remote care management role requiring weekend availability and weekday coverage. The position focuses on reviewing care appropriateness, applying utilization criteria, and coordinating with Health Coaches and case management to improve member outcomes.

Responsibilities include conducting reviews per clinical policies, educating providers, and ensuring privacy and regulatory compliance.

Qualifications

• Current PA RN licensure (or multi-state via eNLC) is required.
• Certification in Utilization Management or related field is preferred.
• 3 years of clinical experience in the area of specialization is required.
• Experience in UM/CM/QA/Managed Care is preferred.
• Experience with acute inpatient and post-acute care settings is preferred.

Responsibilities

• Implement care management review processes per industry and corporate standards.
• Ensure compliance with state and federal laws and regulations.
• Perform care management reviews using approved criteria and policies.
• Promote quality and efficiency in care management delivery.
• Identify and refer members who may benefit from Health Coaching/case management.

Skills

Regulatory compliance

Data analysis

Communication skills

Team player

Multitasking

IT/Software proficiency

Education

Bachelor's Degree in Nursing

Job description

Company

Company : Highmark Inc.

Job Description

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

• RequiredNone
• PreferredBachelor’s Degree in Nursing

EXPERIENCE

• Required3 years of related, progressive clinical experience in the area of specialization
• Experience in a clinical setting
• Preferred3 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

• RequiredCurrent 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.
• PreferredCertification 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 Requirement0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position TypeOffice-BasedTeaches/trains others regularlyOccasionallyTravel regularly from the office to various work sites or from site-to-siteDoes Not ApplyWorks primarily out-of-the office selling products/services (sales employees)Does Not ApplyPhysical work site requiredYesLifting: up to 10 poundsConstantlyLifting: 10 to 25 poundsOccasionallyLifting: 25 to 50 poundsRarely, 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

Pay Range Minimum:$68,400.00

Pay Range Maximum:$105,900.00

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.

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