Remote RN Care Manager: Utilization & Outcomes Expert

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

Job summary

Highmark Inc. is seeking a full-time remote Care Manager to support utilization management activities. The role requires weekend availability (Saturday and Sunday) plus three weekdays, focusing on care review, health coaching referrals, and quality improvement.

You will collaborate with providers and staff, apply established criteria, educate stakeholders, and analyze outcomes to enhance member care and satisfaction. Strong regulatory knowledge and RN licensure are essential.

Qualifications

• 3 years of related, progressive clinical experience
• Experience in UM/CM/QA/Managed Care
• RN licensure in PA or eNLC; additional state licensure may be required

Responsibilities

• Implement care management review processes per standards and guidelines.
• Ensure compliance with state, federal laws and regulatory requirements.
• Conduct care management reviews using established criteria and policies.
• Promote quality and efficiency in care management services.
• Respect patient privacy and adhere to laws.
• Identify and refer members for Health Coaching/case management.
• Educate providers and vendors to improve processes and relationships.
• Develop relationships with internal and external customers.
• Utilize outcomes data to improve services.

Skills

Clinical experience (3+ years)

RN Case Management

Care Management / Utilization review

Data analysis / outcomes

Regulatory compliance

Communication skills

Team collaboration

Time management

Education

RN licensure (PA or eNLC)

Bachelor's Degree in Nursing

Utilization Management certification (preferred)

Tools

Microsoft Office / EMR familiarity

Job description

Highmark Inc. is seeking a full-time remote Care Manager to support utilization management activities. The role requires weekend availability (Saturday and Sunday) plus three weekdays, focusing on care review, health coaching referrals, and quality improvement.

You will collaborate with providers and staff, apply established criteria, educate stakeholders, and analyze outcomes to enhance member care and satisfaction. Strong regulatory knowledge and RN licensure are essential.