Remote RN Care Manager – Utilization & Health Outcomes

Highmark Health; Nashville (TN); A distancia; USD 68.000 - 106.000; Jornada completa

Descripción de la vacante

Highmark Health is seeking a full-time RN Case Manager for a remote role requiring weekend availability and three weekdays. You will implement utilization management strategies, review care appropriateness, and coordinate referrals to Health Coaching and case management.

You will analyze data to improve provider and member satisfaction and respond to inquiries with interventions and alternatives. The role emphasizes adherence to privacy, regulatory compliance, and ethical practice, with

Formación

• Current State of PA RN licensure or multi-state licensure via eNLC.
• 3 years of related clinical experience in care management or UM/CM/QA/Managed Care.
• Experience in UM/CM/QA/Managed Care.
• Experience with acute inpatient and post-acute care.
• Experience with skilled nursing and inpatient rehabilitation.
• Certification in Utilization Management or related field preferred.

Responsabilidades

• Implement care management review processes aligned with industry and corporate standards within the care manager's discipline.
• Ensure compliance with applicable state and federal laws and regulatory requirements.
• Execute all care management reviews per established criteria and medical policies.
• Promote quality and efficiency in care management services.
• Respect member privacy and share only information necessary for care within legal boundaries.
• Practice within ethical principles.
• Identify and refer members who could benefit from Health Coaching/case management interventions.
• Use collaborative interventions to improve member health outcomes and coordinate with providers.
• Educate providers and vendors to streamline processes and build network relationships.
• Develop and sustain positive working relationships with internal and external customers.
• Utilize outcomes data to improve care management services.

Conocimientos

Regulatory compliance

Communication skills

Multitasking

Analytical skills

Organizational skills

Computer skills

Educación

Bachelor's degree in Nursing

Descripción del empleo

Highmark Health is seeking a full-time RN Case Manager for a remote role requiring weekend availability and three weekdays. You will implement utilization management strategies, review care appropriateness, and coordinate referrals to Health Coaching and case management.

You will analyze data to improve provider and member satisfaction and respond to inquiries with interventions and alternatives. The role emphasizes adherence to privacy, regulatory compliance, and ethical practice, with