Remote RN Care Manager - Optimize Care & Outcomes

Highmark Health; Portland (ME); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Inc. is seeking a full-time REMOTE Care Manager to support utilization management. The role requires weekend availability (Sat/Sun) plus three weekdays and focuses on reviewing care appropriateness, applying criteria, and identifying opportunities for Health Coaching referrals.

You will monitor care delivery, educate providers and members, and analyze data to improve outcomes. Responsibilities include implementing reviews per standards, ensuring regulatory compliance, protecting member

Qualifications

• Requires RN licensure in PA or multi-state via eNLC; nursing background preferred.
• Experience in care management or case management is desirable.
• Knowledge of HIPAA and healthcare compliance is important.

Responsibilities

• Implement care management review processes per criteria and guidelines.
• Ensure compliance with state and federal laws and regulatory requirements.
• Apply established criteria and medical policies to reviews.
• Promote quality and efficiency in care management services.
• Protect member privacy and share only information relevant to care.
• Practice ethical principles in daily work.
• Refer members to Health Coaching/case management when appropriate.
• Collaborate to improve processes and build network rapport with providers and vendors.
• Educate providers and facilities to streamline processes and enhance care.
• Develop positive relationships with internal and external customers.
• Use outcomes data to improve care management services.
• Perform other duties as assigned.

Skills

Care management

Regulatory compliance

Data analysis

Written and verbal communication

Team collaboration

Prioritization

Computer skills

Multitasking

Education

Bachelor’s Degree in Nursing

Job description

Highmark Inc. is seeking a full-time REMOTE Care Manager to support utilization management. The role requires weekend availability (Sat/Sun) plus three weekdays and focuses on reviewing care appropriateness, applying criteria, and identifying opportunities for Health Coaching referrals.

You will monitor care delivery, educate providers and members, and analyze data to improve outcomes. Responsibilities include implementing reviews per standards, ensuring regulatory compliance, protecting member