Remote RN Care Manager: Utilization & Case Management

Highmark Health; Sacramento (CA); Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Inc. is seeking a full-time remote care manager in California to support utilization management across weekends and weekdays.

The role reviews care appropriateness, applies criteria to optimize resource use, coordinates with Health Coaching and case management, and helps improve provider and member satisfaction. You will monitor care delivery, educate providers and members, analyze data, and respond to inquiries with effective interventions.

Qualifications

• 3 years of related clinical experience required.
• RN licensure in PA or multi-state via eNLC.
• Experience in UM/CM/QA/Managed Care.
• Experience with acute inpatient and post-acute settings.
• Experience with skilled nursing and inpatient Rehab.
• Preferred: Bachelor's Degree in Nursing.

Responsibilities

• Implement care management review processes per standards and discipline.
• Ensure compliance with state and federal laws and regulatory requirements.
• Apply established criteria and guidelines to care reviews.
• Promote quality and efficiency in care management services.
• Respect member privacy and data confidentiality.
• Refer members to Health Coaching/case management when appropriate.
• Educate providers and vendors to streamline processes and build relationships.
• Develop positive working relationships with internal and external customers.
• Utilize outcomes data to improve care management services.
• Other duties as assigned.

Skills

Regulatory compliance

Data analysis

Written and verbal communication

Multi-tasking

Team player

Prioritization

Computer skills

Education

Bachelor’s Degree in Nursing

Tools

UM/CM software

Job description

Highmark Inc. is seeking a full-time remote care manager in California to support utilization management across weekends and weekdays.

The role reviews care appropriateness, applies criteria to optimize resource use, coordinates with Health Coaching and case management, and helps improve provider and member satisfaction. You will monitor care delivery, educate providers and members, analyze data, and respond to inquiries with effective interventions.