Remote RN Care Manager: Utilization & Care Coordination

Highmark Health; Rhode Island; Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Health is hiring for a remote Care Management role requiring weekend availability (Saturday and Sunday) plus three weekdays. The incumbent will review appropriateness of health care services, apply criteria for resource utilization, and identify opportunities for referral to Health Coaching and case management.

The role emphasizes educating providers and members, analyzing data to improve provider and member satisfaction, and addressing quality issues.

Qualifications

• Requires RN licensure and nursing degree.
• Experience in UM/CM/QA/ Managed Care is preferred.
• Strong understanding of healthcare regulations and privacy standards.

Responsibilities

• Implement care management reviews per established criteria and guidelines.
• Ensure compliance with state and federal laws and regulations.
• Identify opportunities for referral to Health Coaching or case management.
• Promote quality and efficiency in care management services.
• Educate providers and vendors to streamline processes and improve outcomes.
• Develop relationships with internal and external customers.
• Utilize outcomes data to improve ongoing care management services.

Skills

Regulatory compliance

Data analysis

Communication skills

Team collaboration

Utilization management

Education

Bachelor’s Degree in Nursing

Job description

Highmark Health is hiring for a remote Care Management role requiring weekend availability (Saturday and Sunday) plus three weekdays. The incumbent will review appropriateness of health care services, apply criteria for resource utilization, and identify opportunities for referral to Health Coaching and case management.

The role emphasizes educating providers and members, analyzing data to improve provider and member satisfaction, and addressing quality issues.