Remote RN Care Manager: Utilization & Case Management

Highmark Health; Clifton (TX); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Health is seeking a remote Care Management professional with weekend availability (Saturday and Sunday) and three weekdays. You will implement utilization review processes, apply policy criteria, and identify opportunities for referral to Health Coaching and case management.

Responsibilities include educating providers, analyzing data to improve provider and member satisfaction, and collaborating with internal and external teams to drive quality outcomes.

Qualifications

• RN licensure in PA or eligible for multi-state via eNLC.
• Bachelor’s Degree in Nursing preferred.
• 3 years clinical experience in care management.
• Experience in UM/CM/QA/Managed Care preferred.
• Knowledge of privacy and HIPAA.

Responsibilities

• Implement care management reviews per industry and policy standards.
• Ensure compliance with state and federal laws.
• Apply criteria and guidelines to care management reviews.
• Promote quality and efficiency in care management services.
• Protect member privacy and share only relevant information.
• Educate providers and vendors to streamline processes.
• Refer members to Health Coaching/case management when appropriate.
• Develop relationships with internal and external customers.

Skills

Care management

Healthcare policy

Data analysis

Communication skills

Regulatory knowledge

Team collaboration

Education

Nursing licensure

Tools

EHR systems

Job description

Highmark Health is seeking a remote Care Management professional with weekend availability (Saturday and Sunday) and three weekdays. You will implement utilization review processes, apply policy criteria, and identify opportunities for referral to Health Coaching and case management.

Responsibilities include educating providers, analyzing data to improve provider and member satisfaction, and collaborating with internal and external teams to drive quality outcomes.