Medical Case Manager - PDN/Private Duty Nursing (Delaware)

Highmark Health Company; New York (NY); Hybrid; USD 73,000 - 117,000; Full time

Job summary

Highmark Inc. is seeking a full-time Case Manager to deliver comprehensive case management services within the assigned territory in DE.

The role involves assessing member needs, developing and implementing care plans, coordinating services, and monitoring progress to ensure quality and cost-effective care. You will detect and prevent improper utilization of benefits while collaborating with physicians and the health care team to meet member goals.

Qualifications

• 3 years of experience in case or utilization management or health insurance with RN licensure or a MSW.
• 5 years of experience with a Bachelor’s in Social Work.
• Pediatric, Medicaid/Medicare experience, and cultural competence in care.

Responsibilities

• Manage a caseload of members with moderate complexity health needs.
• Assess members’ health status, needs, and available resources.
• Develop individualized care plans with members, physicians, and other providers.
• Coordinate referrals to specialists and community resources.
• Monitor member progress toward goals and adjust care plans as needed.
• Ensure documentation complies with policies and HIPAA and related regulations.
• Identify areas for cost savings, quality improvement, and workflow efficiencies.
• Collaborate with the health care team to carry out the plan of care.

Skills

Assessment & care planning

Independent & team work

MS Office & EHR

Healthcare systems knowledge

Bilingual English/Spanish

Education

Nursing degree or RN licensure

MSW or Social Work degree

Tools

Case management software

Electronic Health Records (EHRs)

Job description

Company: Highmark Inc.

Job Summary

This is a full-time position requiring frequent travel within the assigned territory in DE.

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 minimal guidance.
• 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.

Experience

Required

• 3 years of experience in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience with RN licensure or a Master’s degree OR; 5 years’ experience with a Bachelor’s in Social Work

Preferred

• Pediatric experience
• Medicaid managed care and/or Medicare experience
• Experience working with the healthcare needs of diverse populations
• Experience demonstrating understanding of importance of culture competency in addressing targeted populations

Skills

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

Education

Required

• Bachelor’s degree in nursing or RN licensure or Master’s degree in Social Work, Counseling, or related field OR Bachelor’s degree in Social Work

Preferred

• None

Licenses or Certifications

Required

• Licensed Social Worker (LSW)-Non-Specific - State (OR) Licensed Professional Counselor (LPC) - Non-Specific State (OR) Licensed Bachelors Social Worker (LBSW) (OR) Licensed Clinical Social Worker (LCSW) - Non-Specific (OR) Licensed Master Social Worker (LMSW) Non-Specific (OR) Licensed Graduate Social Worker (LGSW) (OR) Licensed Certified Social Worker (LCSW) (OR) Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Incumbents in the role prior to 1/1/25 who are not currently licensed must obtain licensure by 12/31/27.

Preferred

• Certified Case Manager (CCM)

Language (Other than English): None

Travel Required: 0% - 25%

Position Type

Office-Based or Remote Position

Physical work site required 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 job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

HIPAA and Privacy

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: $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.

Discrimination Information

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 Notice

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