Remote RN Care Manager — Utilization & Care Coordination

Highmark Health; East Windsor Hill (CT); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Health is seeking a full-time remote RN case manager to implement utilization management strategies, review care appropriateness, and coordinate referrals to Health Coaching/case management. The role requires weekend availability (Saturday and Sunday) in addition to three weekdays and focuses on improving provider and member satisfaction.

The position emphasizes regulatory compliance, data analysis of care outcomes, and collaborative interventions to optimize care options and network

Qualifications

• ~ RN licensure in PA or multi-state licensure via eNLC may be required depending on location.
• ~ 3 years of related, progressive clinical experience in care management.
• ~ Experience in a clinical setting.
• ~ Certification in Utilization Management or related field (preferred).
• ~ Knowledge of UM/CM/QA/Managed Care concepts.

Responsibilities

• Implement care management review processes consistent with industry and corporate standards.
• Function in accordance with applicable state, federal laws and regulatory compliance.
• Implement care management reviews according to established criteria and guidelines.
• Promote quality and efficiency in the delivery of care management services.
• Respect the member's privacy and share only information relevant to care.
• Practice within ethical principles.
• Identify and refer members to Health Coaching/case management interventions.
• Collaborate to streamline processes and develop network relationships.
• Develop and sustain positive working relationships with internal and external customers.
• Utilize outcomes data to improve ongoing care management services.
• Other duties as assigned or requested

Skills

Regulatory knowledge

Multitasking

Communication skills

Data analysis

Adaptability

Team player

Analytical skills

Organizational skills

Education

Bachelor’s Degree in Nursing

Job description

Highmark Health is seeking a full-time remote RN case manager to implement utilization management strategies, review care appropriateness, and coordinate referrals to Health Coaching/case management. The role requires weekend availability (Saturday and Sunday) in addition to three weekdays and focuses on improving provider and member satisfaction.

The position emphasizes regulatory compliance, data analysis of care outcomes, and collaborative interventions to optimize care options and network