Remote RN Care Manager - Utilization & Care Coordination

Highmark Health; Bristol (RI); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Health is seeking a remote Care Manager with RN licensure to support utilization management. The role requires weekend availability (Sat/Sun) plus three weekdays, with focus on review of services, criteria-based decisions, and referrals to Health Coaching or case management.

Responsibilities include implementing care management reviews, ensuring regulatory compliance, and promoting quality, efficiency, and privacy in care delivery.

Qualifications

• Knowledge of regulatory and compliance guidelines governing healthcare.
• Ability to analyze qualitative and quantitative data to improve care and provider performance.
• Excellent written and verbal communication to educate providers and members.

Responsibilities

• Implement care management reviews per established criteria and policies.
• Ensure compliance with state and federal laws and corporate standards.
• Promote quality and efficiency in care management services.
• Identify members who could benefit from Health Coaching or case management.
• Educate providers and vendors to streamline processes and build network rapport.
• Use outcomes data to improve ongoing care management services.

Skills

Regulatory compliance

Data analysis

Communication skills

HIPAA knowledge

Team collaboration

Quality improvement

Education

Bachelor’s Degree in Nursing

Job description

Highmark Health is seeking a remote Care Manager with RN licensure to support utilization management. The role requires weekend availability (Sat/Sun) plus three weekdays, with focus on review of services, criteria-based decisions, and referrals to Health Coaching or case management.

Responsibilities include implementing care management reviews, ensuring regulatory compliance, and promoting quality, efficiency, and privacy in care delivery.