Remote RN Care Manager — Utilization & Outcomes Leader

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

Job summary

Highmark Health is seeking an experienced registered nurse for a remote full-time care management role requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

The role involves evaluating care appropriateness, applying utilization criteria, referring to Health Coaching/case management, and addressing quality issues while educating providers and members to improve satisfaction and outcomes.

Qualifications

• 3 years of related, progressive clinical experience in the area of specialization.
• Experience in a clinical setting.
• Current PA RN licensure or multi-state licensure via eNLC; other state licensure may be required depending on where care is provided.
• Certification in Utilization Management or related field is preferred.

Responsibilities

• Implement care management review processes that align with industry and corporate standards.
• Ensure compliance with applicable state and federal laws and regulatory requirements.
• Perform care management reviews according to established criteria and medical policies.
• Promote quality and efficiency in care management services.
• Protect member privacy and share only information relevant to care within legal limits.
• 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 navigate available resources.
• Educate providers and vendors to streamline processes and strengthen network relationships.
• Develop positive working relationships with internal and external customers.
• Utilize outcomes data to improve ongoing care management services.
• Perform other duties as assigned.

Skills

Regulatory compliance

Multi-tasking

Communication skills

Data analysis

Enthusiastic & flexible

Team player

Time management

Computer proficiency

Education

Bachelor's Degree in Nursing

Job description

Highmark Health is seeking an experienced registered nurse for a remote full-time care management role requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

The role involves evaluating care appropriateness, applying utilization criteria, referring to Health Coaching/case management, and addressing quality issues while educating providers and members to improve satisfaction and outcomes.