Remote RN Care Manager: Health Outcomes & Coordination

Highmark Health; Philadelphia (Philadelphia County); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Health is seeking a full-time RN for a remote care management role requiring weekend availability and weekday coverage. The position focuses on reviewing care appropriateness, applying utilization criteria, and coordinating with Health Coaches and case management to improve member outcomes.

Responsibilities include conducting reviews per clinical policies, educating providers, and ensuring privacy and regulatory compliance.

Qualifications

• Current PA RN licensure (or multi-state via eNLC) is required.
• Certification in Utilization Management or related field is preferred.
• 3 years of clinical experience in the area of specialization is required.
• Experience in UM/CM/QA/Managed Care is preferred.
• Experience with acute inpatient and post-acute care settings is preferred.

Responsibilities

• Implement care management review processes per industry and corporate standards.
• Ensure compliance with state and federal laws and regulations.
• Perform care management reviews using approved criteria and policies.
• Promote quality and efficiency in care management delivery.
• Identify and refer members who may benefit from Health Coaching/case management.

Skills

Regulatory compliance

Data analysis

Communication skills

Team player

Multitasking

IT/Software proficiency

Education

Bachelor's Degree in Nursing

Job description

Highmark Health is seeking a full-time RN for a remote care management role requiring weekend availability and weekday coverage. The position focuses on reviewing care appropriateness, applying utilization criteria, and coordinating with Health Coaches and case management to improve member outcomes.

Responsibilities include conducting reviews per clinical policies, educating providers, and ensuring privacy and regulatory compliance.