Remote RN Care Manager: Utilization & Care Coordination

highmarkhealth; United States; Remote; USD 75,000 - 100,000; Full time

Job summary

Highmark Inc. is seeking a full-time RN with utilization management expertise for a remote role requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

The position focuses on reviewing care appropriateness, applying criteria, and coordinating with Health Coach/case management to improve member outcomes. Responsibilities include implementing care management reviews, ensuring regulatory compliance, educating providers and vendors, and analyzing data to develop action

Qualifications

• RN licensure in PA or multi-state licensure via eNLC.
• Bachelor's Degree in Nursing is preferred.
• 3 years of related, progressive clinical experience.
• Experience in UM/CM/QA/Managed Care.
• Experience with acute inpatient and post-acute settings.
• Ability to educate providers and vendors to streamline processes.

Responsibilities

• Implement care management review processes consistent with industry and corporate standards.
• Comply with applicable state, federal laws and regulatory requirements.
• Follow established criteria and guidelines for care management reviews.
• Promote quality and efficiency in care management services.
• Respect patient privacy and share information only as allowed by law.
• Identify and refer patients who could benefit from Health Coaching/case management.

Skills

Excellent communication

Data analysis

Multi-tasking

Team player

Regulatory knowledge

Patient-focused care

Education

Bachelor's Degree in Nursing

Job description

Highmark Inc. is seeking a full-time RN with utilization management expertise for a remote role requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

The position focuses on reviewing care appropriateness, applying criteria, and coordinating with Health Coach/case management to improve member outcomes. Responsibilities include implementing care management reviews, ensuring regulatory compliance, educating providers and vendors, and analyzing data to develop action