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

highmarkhealth; États-Unis; À distance; USD 75 000 - 100 000; Plein temps

Résumé du poste

Highmark Inc. is seeking a full-time RN with utilization management expertise for a remote role requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

The position focuses on reviewing care appropriateness, applying criteria, and coordinating with Health Coach/case management to improve member outcomes. Responsibilities include implementing care management reviews, ensuring regulatory compliance, educating providers and vendors, and analyzing data to develop action

Qualifications

• RN licensure in PA or multi-state licensure via eNLC.
• Bachelor's Degree in Nursing is preferred.
• 3 years of related, progressive clinical experience.
• Experience in UM/CM/QA/Managed Care.
• Experience with acute inpatient and post-acute settings.
• Ability to educate providers and vendors to streamline processes.

Responsabilités

• Implement care management review processes consistent with industry and corporate standards.
• Comply with applicable state, federal laws and regulatory requirements.
• Follow established criteria and guidelines for care management reviews.
• Promote quality and efficiency in care management services.
• Respect patient privacy and share information only as allowed by law.
• Identify and refer patients who could benefit from Health Coaching/case management.

Connaissances

Excellent communication

Data analysis

Multi-tasking

Team player

Regulatory knowledge

Patient-focused care

Formation

Bachelor's Degree in Nursing

Description du poste

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 Handboo