Remote RN Care Manager | Utilization & Care Coordination

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

Job summary

Highmark Health is seeking a remote Care Management Nurse/CM Specialist to implement utilization management strategies across weekdays and weekends. The role reviews care appropriateness, applies criteria for resource use, and refers to Health Coaching or case management as needed.

You will educate providers and members, analyze qualitative and quantitative data to improve provider and member satisfaction, and respond to inquiries with timely interventions.

Qualifications

• RN with clinical experience in care management or UM/CM.
• Strong understanding of health care policy and privacy.
• Experience in quality improvement and patient education.

Responsibilities

• Implement care management review processes aligned with industry standards.
• Ensure compliance with applicable laws and regulatory guidelines.
• Apply criteria for appropriate service utilization and care planning.
• Refer members to Health Coaching/case management when needed.
• Educate providers and vendors to streamline processes.
• Develop positive relationships with internal and external customers.
• Use outcomes data to improve care management services.
• Respond to customer inquiries and offer interventions when needed.

Skills

Excellent written and verbal commu­n

Ability to multi task

Data analysis

Team player

Organizational skills

Education

Bachelor’s Degree in Nursing

Job description

Highmark Health is seeking a remote Care Management Nurse/CM Specialist to implement utilization management strategies across weekdays and weekends. The role reviews care appropriateness, applies criteria for resource use, and refers to Health Coaching or case management as needed.

You will educate providers and members, analyze qualitative and quantitative data to improve provider and member satisfaction, and respond to inquiries with timely interventions.