Remote RN Care Manager for Utilization & Outcomes

Highmark Health; Baltimore (MD); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Inc. is seeking a full-time remote Care Manager.

This role requires weekend availability (Saturday and Sunday) in addition to three weekdays, and focuses on utilization management, provider education, and data-driven improvements to member satisfaction. Responsibilities include implementing care management reviews, ensuring compliance with laws, promoting quality, identifying referrals to Health Coaching, educating providers, and building strong internal and external relationships.

Qualifications

• 3+ years of clinical experience in care management or related field.
• Current RN license in PA or multi-state via eNLC; state requirements may vary.
• Experience with UM/CM/QA/Managed Care is preferred.

Responsibilities

• Implement care management reviews per criteria and guidelines.
• Ensure compliance with state and federal laws.
• Apply medical policies to care management reviews.
• Promote quality and efficiency in care delivery.
• Protect member privacy and limit data disclosure.
• Practice ethical principles in all activities.
• Refer members to Health Coaching/case management when appropriate.
• Collaborate with providers to streamline processes and build relationships.
• Educate providers and vendors to improve procedures.
• Maintain positive relationships with internal and external customers.
• Use outcomes data to drive service improvements.
• Perform other duties as assigned.

Skills

Regulatory compliance

Multitasking

Written & verbal comms

Data analysis

Innovative & flexible

Team player

Time management

Computer skills

Education

Bachelor's Degree in Nursing

Job description

Highmark Inc. is seeking a full-time remote Care Manager.

This role requires weekend availability (Saturday and Sunday) in addition to three weekdays, and focuses on utilization management, provider education, and data-driven improvements to member satisfaction. Responsibilities include implementing care management reviews, ensuring compliance with laws, promoting quality, identifying referrals to Health Coaching, educating providers, and building strong internal and external relationships.