RN Care Manager: Outcomes & Care Coordination

Highmark Health Company; United States; Remote; USD 68,000 - 106,000; Full time

Job summary

Highmark Inc. is seeking a registered nurse to implement utilization management strategies, review care appropriateness, and apply criteria to guide referrals to Health Coaching and case management.

The role involves analyzing data to improve provider performance and member satisfaction while educating providers and members. The position requires clinical experience, PA RN licensure or eNLC, and knowledge of UM/CM processes; preferred nursing degree and managed care exposure.

Qualifications

• 3 years of related, progressive clinical experience
• Current PA RN licensure or multi-state licensure through eNLC
• Bachelor’s Degree in Nursing preferred
• Experience in UM/CM/QA/Managed Care preferred

Responsibilities

• Implement care management reviews aligned with industry standards.
• Ensure compliance with state and federal laws and regulations.
• Apply established criteria and guidelines to care management reviews.
• Promote quality and efficiency in care management services.
• Educate providers and vendors to streamline processes.
• Develop and sustain relationships with internal and external customers.
• Utilize outcomes data to improve care management performance.
• Identify members who may benefit from Health Coaching/case management.

Skills

Regulatory guidelines

Multitasking

Communication skills

Data analysis

Adaptability

Organizational skills

Prioritization

Computer skills

Education

Bachelor’s Degree in Nursing

Job description

Highmark Inc. is seeking a registered nurse to implement utilization management strategies, review care appropriateness, and apply criteria to guide referrals to Health Coaching and case management.

The role involves analyzing data to improve provider performance and member satisfaction while educating providers and members. The position requires clinical experience, PA RN licensure or eNLC, and knowledge of UM/CM processes; preferred nursing degree and managed care exposure.