Senior Case Manager RN - Oncology (Remote)

Highmark Health; Town of King (WI); Remote; USD 114,000 - 140,000; Full time

Job summary

Highmark Health is seeking an experienced Case Manager to deliver comprehensive case management for members, develop care plans, coordinate services, and monitor outcomes while containing costs.

The role requires 5 years of relevant experience, an active RN license, and CCM certification within 36 months. Strong collaboration with physicians and care teams, plus EHR proficiency, are essential for successful performance.

Qualifications

• 5 years of clinical, case/utilization management, or health insurance experience.
• RN licensure active; CCM certification to be obtained within 36 months.
• Experience with diverse populations and complex care needs.
• Advanced training in CBT, motivational interviewing, or DBT.
• Proficiency with Microsoft Office, case management software and EHRs.

Responsibilities

• Manage a caseload of members with complex health needs.
• Assess health status and develop individualized care plans.
• Coordinate services and ensure access to required resources.
• Monitor progress and adjust plans to meet goals.
• Advocate and liaise to meet members' health care needs.
• Document activities per policies; ensure HIPAA and compliance.
• Provide guidance to lower-level Case Managers.

Skills

Complex case management

CBT / Motivational Interviewing / DBT

Coordination of care

Advocacy

EHR proficiency

Interdisciplinary collaboration

Nursing background

Regulatory/compliance knowledge

Education

Bachelor of Science in Nursing

RN licensure (state)

CCM certification within 36 months

Tools

Microsoft Office

Case management software

Electronic health records (EHR)

Job description

This job is responsible for providing comprehensive case management services to members, ensuring quality, cost-effective care delivery, and promoting optimal health outcomes. The Case Manager assesses member needs, develops and implements care plans, coordinates services, and monitors progress, while containing the cost of health care services. The incumbent will assist in containing the cost of health care services by detecting, resolving and preventing improper utilization of member benefits.

Responsibilities

• Manage a caseload of members with complex health needs, requiring advanced clinical knowledge.
• Conduct comprehensive assessments and develop complex care plans.
• Assess members’ health status, needs, and available resources.
• Develop individualized care plans in collaboration with members, physicians, and other healthcare providers.
• Implement and coordinate care plans, ensuring access to appropriate services and resources.
• Monitor member progress toward goals and adjust care plans as needed.
• Act as an advocate and liaison to meet a member's individual health care needs by assessing, planning, implementing, coordinating, monitoring and evaluating options and services. This is accomplished by using communication and available resources to promote quality, cost-effective outcomes in accordance with available contract benefits.
• Work collaboratively and communicate clearly and professionally with physicians, providers, co-workers and other members of the health care team to carry out the established plan of care.
• Ensure all activities are documented and conducted in compliance with applicable business process requirements, company policies, regulatory requirements and accreditation standards.
• Provide guidance and mentorship to lower-level Case Managers.
• Serve as a resource for clinical expertise and problem-solving.

Qualifications

• 5 years in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience.
• Oncology, Transplant, Maternity, NICU, Pediatric)
• Experience working with the healthcare needs of diverse populations
• Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing, or dialectical behavior therapy (DBT)
• .
• Expertise in clinical assessment and care planning.
• Proficiency in using Microsoft suite of applications, case management software and electronic health records.
• Strong understanding of healthcare systems and case management principles.
• Bachelors in Nursing.

Licensure and Certification

• Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
• Certified Case Manager (CCM) certification must be obtained within 36 months of hire. OCN, CPN, CPON, CNN, CCTC, CPHQ).

Additional Information

• Language (Other than English):
• ~ Travel Required:
• ~ Office-Based or Remote Position
• Physical work site required

It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

127,100.00 Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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