RN Care Manager: Care Coordination & Transitions

Highmark Health; Pittsburgh (Allegheny County); On-site; USD 90,000 - 120,000; Full time

Job summary

Allegheny Health Network is seeking a registered nurse skilled in care management to lead coordination of care across settings, promote efficient transitions, and support optimal resource use for diverse patient populations.

The role emphasizes collaboration with care teams, securing approvals with payers, documenting outcomes, and educating staff while abiding by regulatory standards and HIPAA requirements. Strong critical thinking and communication are essential for success.

Qualifications

• Bachelor’s degree in nursing or equivalent, or 6 years relevant experience.
• At least 3 years in a clinical nursing role.
• Current PA RN licensure or multi-state licensure via eNLC.
• Professional certification within 5 years of start date.
• Strong critical thinking, communication, and collaboration skills.
• CPR certification and background clearances as required.

Responsibilities

• Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
• Facilitates development and communication of the continuum of care transition plan to appropriate health service providers.
• Documents, verifies, and validates data to monitor and evaluate interventions and outcomes.
• Obtains pre-certifications from third party payers and placement to appropriate level of care prior to hospitalization.
• Documents, monitors, and reports clinical denials/appeals and retrospective payer audit denials.
• Maintains knowledge of care management regulations and adheres to policies and HIPAA requirements.
• Serves as an educational resource to AHN staff regarding utilization review practice and guidelines.
• Performs continued education and professional growth.

Skills

Care coordination

Assessment

Communication

Regulatory compliance

Denials/Appeals

Education

Bachelor’s Degree in Nursing

Nursing Diploma

6 years relevant experience

Job description

Allegheny Health Network is seeking a registered nurse skilled in care management to lead coordination of care across settings, promote efficient transitions, and support optimal resource use for diverse patient populations.

The role emphasizes collaboration with care teams, securing approvals with payers, documenting outcomes, and educating staff while abiding by regulatory standards and HIPAA requirements. Strong critical thinking and communication are essential for success.