Remote RN Care Manager: Utilization & Care Coordination

Highmark Health; Town of King (WI); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Health in the United States is seeking a Nurse for Utilization Management in a fully remote role requiring weekend availability (Saturday and Sunday) in addition to three weekdays. The position focuses on review of health care services, applying criteria to ensure appropriate resource use, and identifying opportunities for referral to Health Coaching and case management.

You will educate providers and members, analyze data to improve provider performance and member satisfaction, and

Qualifications

• 3 years of related, progressive clinical experience in the area of specialization.
• Experience in a clinical setting.
• Regulatory compliance knowledge and ability to apply policies.

Responsibilities

• Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.
• Function in accordance with applicable state, federal laws and regulatory compliance.
• Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
• Promote quality and efficiency in the delivery of care management services.
• Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws.
• Practice within the scope of ethical principles.
• Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
• Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and 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 compliance knowledge

Data analysis

Written and verbal communication

Analytical and organizational skills

Team player

Education

Bachelor’s Degree in Nursing

Job description

Highmark Health in the United States is seeking a Nurse for Utilization Management in a fully remote role requiring weekend availability (Saturday and Sunday) in addition to three weekdays. The position focuses on review of health care services, applying criteria to ensure appropriate resource use, and identifying opportunities for referral to Health Coaching and case management.

You will educate providers and members, analyze data to improve provider performance and member satisfaction, and