Case Manager RN (Remote)

Highmark Health; Northern (KY); Hybrid; USD 73,000 - 117,000; Full time

Job summary

Highmark Inc. is seeking a Case Manager to deliver comprehensive case management for members, assessing needs, developing and coordinating care plans, and monitoring progress to ensure quality outcomes while containing costs.

The role requires an RN license, 3 years in case/ utilization management, and strong skills in assessment, care planning, and collaboration with physicians, providers, and health teams. Travel is 0%–25%.

Qualifications

• High School Diploma or GED required.
• Bachelor's Degree in Nursing preferred.
• 3 years of clinical/case management experience required.
• RN licensure current in PA or multi-state eNLC/other states within 6 months.

Responsibilities

• Manage a caseload of members with moderate complexity health needs.
• Assess health status, needs, and resources.
• Develop individualized care plans with members and providers.
• Coordinate referrals and services across care continuum.
• Monitor progress and adjust care plans as needed.
• Ensure documentation complies with HIPAA and policies.
• Identify opportunities for cost savings and quality improvement.

Skills

Assessment skills

Care planning

Independent / team work

MS Office / EHR

Healthcare systems knowledge

Education

High School Diploma/GED

Bachelor's Degree in Nursing

Tools

Microsoft Office

Case management software

Electronic Health Records (EHR)

Job description

Company : Highmark Inc.

JOB SUMMARY

This job is responsible for providing comprehensive case management services to members, ensuring quality, cost-effective care delivery, and promoting optimal health outcomes. The Case Manager assesses member needs, develops and implements care plans, coordinates services, and monitors progress, while containing the cost of health care services. The incumbent will assist in containing the cost of health care services by detecting, resolving and preventing improper utilization of member benefits.

ESSENTIAL RESPONSIBILITIES

• Manage a caseload of members with moderate complexity health needs.
• 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.
• Develop and implement care plans with guidance from senior staff.
• Coordinate referrals to specialists and community resources.
• Monitor member progress toward goals and adjust care plans as needed.
• Evaluate the effectiveness of interventions and services.
• Act as an advocate and liaison to meet a member's individual health care needs by assessing, planning, implementing, coordinating, monitoring and evaluating options and services.
• This is accomplished by using communication and available resources to promote quality, cost-effective outcomes in accordance with available contract benefits.
• Work collaboratively and communicate clearly and professionally with physicians, providers, co-workers and other members of the health care team to carry out the established plan of care.
• Ensure all activities are documented and conducted in compliance with applicable business process requirements, company policies, regulatory requirements and accreditation standards.
• Identify areas for potential cost savings, quality improvement and workflow efficiencies.
• Other duties as assigned or requested.

EDUCATION

Required: High School Diploma/GED Substitutions None

Preferred: Bachelor's Degree in Nursing

EXPERIENCE

Required: 3 years in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience.

• Utilization Management
• Registered Nurse Case Management Experience working with the healthcare needs of diverse populations
• Experience demonstrating understanding of the importance of cultural competency in addressing targeted populations

LICENSES AND CERTIFICATIONS

Required: Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment.

SKILLS

• Strong assessment and care planning skills.
• Ability to work independently and as part of a team.
• Proficiency in using Microsoft suite of applications, case management software and electronic health records.
• Understanding of healthcare systems and case management principles

LANGUAGE REQUIREMENT

None

TRAVEL REQUIREMENT

0% - 25%

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS

Position Type Office-Based Physical Work Site Required

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 job 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: $72,700.00 Pay Range Maximum: $116,600.00

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.

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California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.