Medical Case Manager (West Virginia)

Highmark Health; West Virginia; Remote; USD 57,000 - 108,000; Full time

Job summary

An established industry player is seeking a Medical Case Manager to ensure members with complex medical needs receive high-quality, cost-effective care. In this dynamic role, you will assess, plan, and coordinate healthcare services while advocating for optimal care plans. You'll work closely with healthcare providers and members, utilizing your clinical judgment to navigate the healthcare landscape effectively. This position offers an opportunity to make a significant impact on member health outcomes while working in a supportive and collaborative environment. If you're passionate about healthcare and dedicated to improving lives, this role is perfect for you.

Qualifications

• Bachelor's degree in nursing or social work with relevant experience.
• 3-5 years in Acute or Managed Care with Medicaid/Medicare populations.

Responsibilities

• Facilitate access to healthcare for members with complex needs.
• Collaborate with healthcare providers to coordinate member care.
• Develop individualized care plans and monitor progress.

Skills

Communication Skills

Clinical Judgment

Knowledge of Medical Terminology

Care Coordination

Education

Bachelor’s degree in nursing

Master’s degree in Social Work

Bachelor’s degree in Social Work

Job description

Thank you for your interest in employment at a Highmark Health company. Highmark Health uses an online application process. If you participate in the online application process through this Workday site, your personal information will be collected, including but not limited to data such as your resume and resume content, education, contact information, address, city, postal code, country, phone number, email address, IP address, as well as any other personal information you choose to provide. As part of the online application process, we will provide details such as how we will use the data that we collect and where such information is processed. We will also ask for your consent to use the data for purposes contained in the Highmark Health Data Protection Statement and the GDPR Data Protection Consent for Job Applicants, and for all other permissible purposes.

Medical Case Manager (West Virginia)

Apply remote type Remote locations WV, Working at Home - W Virginia time type Full time posted on Posted Yesterday job requisition id J261461

Company :

Highmark Inc.

Job Description :

JOB SUMMARY
This job assures that members with complex medical and/or psychosocial needs have access to high quality, cost-effective health care. Assists in the holistic assessment, planning, arranging, coordinating, monitoring, evaluation of outcomes and activities necessary to facilitate member access to healthcare services. Advocates for the most appropriate care plan using sound clinical judgment; accurate planning, and collaboration with internal and/or external customers and contacts. Follows established regulatory guidelines, policies, and procedures in relation to member interventions and documentation of activities related to the member’s care and progress across the continuum of care. Facilitates and/or participates in interdisciplinary and/or interagency meetings, when necessary, to facilitate coordination of services/resources for members.

ESSENTIAL RESPONSIBILITIES

• Communicate effectively while performing customer telephonic interviewing and communication with external contacts.
• Communicate effectively while interacting with Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.
• Maintain knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States.
• Educate members to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes.
• Collaborate with Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care.
• Collect member medical information from a variety of sources including providers and internal records and use appropriate clinical judgment, consultation with internal Physician Advisors and other internal cross-departmental consultation to determine unmet member needs.
• Work primarily independently to identify, define, and resolve a myriad of problem types experienced by the member.
• Develop an individualized plan of care designed to meet the specific needs of each member.
• Anticipate the needs of members by continually assessing and monitoring the member’s progress toward goals, care plan status, and re-adjust goals when indicated.
• Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services.
• Be knowledgeable of and consider benefit design and cost benefit analysis when planning a course of intervention to develop a realistic plan of care.
• Communicate and collaborate with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
• Maintain a working knowledge of available community resources available to assist members.
• Coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible.
• Work within a Team Environment.
• Attend and participate in required meetings, including staff meetings, internal Rounds, and other in-services to enhance professional knowledge and competency for overall management of members.
• Participate in departmental and/or organizational work and quality initiative teams.
• Case collaborate with peers, Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.
• Participate in interagency and/or interdisciplinary team meetings when necessary to facilitate coordination of member care and resources.
• Foster effective work relationships through conflict resolution and constructive feedback skills.
• Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.
• Educate health team colleagues of the role and responsibility of Case Management and the unique needs of the populations served to foster constructive and collaborative solutions to meet member needs.
• Other duties as assigned or requested.

QUALIFICATIONS

Minimum

• Bachelor’s degree in nursing or RN certification in lieu of bachelor's degree or Master’s degree in Social Work, Counseling, Education, or related field and 3 years' experience in Acute or Managed Care/ experience with Medicaid or Medicare populations. OR
• Bachelor’s degree in Social Work with five years’ experience in Acute or Managed Care/ experience with Medicaid or Medicare populations.

Preferred

• Experience working with high-risk pregnant women OR experience working with chronic condition adult populations OR experience with pediatrics.
• 3 years of experience in working in Acute Care/Managed Care/Medicaid and Medicare populations.
• Case Management Certification.

LICENSES AND CERTIFICATIONS

Required

• Licensed Social Worker (LSW)-Non-Specific - State (OR) Registered Nurse - Non-Specific (OR) Licensed Professional Counselor (LPC) – Non-Specific State.

Preferred

• RN license in WV is required or Compact state license.

Skills

• None.

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No.

WORK ENVIRONMENT

Is Travel Required?

No.

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.

Pay Range Minimum:

$57,700.00

Pay Range Maximum:

$107,800.00

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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