RN Care Manager: Utilization & Case Management

Highmark Inc; Pennsylvania; Hybrid; USD 68,000 - 106,000; Full time

Job summary

Highmark Inc. is seeking a care management professional to implement utilization management strategies, review care appropriateness, and identify opportunities for Health Coaching and case management interventions.

You will work to improve provider performance and member satisfaction while ensuring privacy and regulatory compliance. Responsibilities include conducting reviews, educating providers, and collaborating with internal/external stakeholders.

Qualifications

• 3 years of related, progressive clinical experience in the area of specialization.
• RN licensure in PA or eNLC where applicable.
• Certification in utilization management or related field preferred.

Responsibilities

• Implement care management reviews per established criteria and policies.
• Ensure compliance with state/federal laws and regulations.
• Promote quality and efficiency in care management services.
• Educate providers and members to improve outcomes and satisfaction.
• Refer members to Health Coaching/case management when appropriate.

Skills

RN licensure

UM/CM experience

Data analysis

Regulatory compliance

Written and verbal communication

HIPAA compliance

Education

Bachelor’s Degree in Nursing

Tools

Microsoft Office

Job description

Highmark Inc. is seeking a care management professional to implement utilization management strategies, review care appropriateness, and identify opportunities for Health Coaching and case management interventions.

You will work to improve provider performance and member satisfaction while ensuring privacy and regulatory compliance. Responsibilities include conducting reviews, educating providers, and collaborating with internal/external stakeholders.