Senior Case Manager RN (Remote)

Highmark; United States; On-site; USD 79,000 - 127,000; Full time

Job summary

Highmark Inc. is seeking an experienced Case Manager to provide comprehensive case management services to members, develop and implement care plans, and coordinate services to promote optimal health outcomes.

You will assess member needs, monitor progress, and act as an advocate to contain costs while delivering high-quality care. This role requires strong clinical knowledge, leadership, and collaboration with the health care team.

Qualifications

• Experience in clinical case management and utilization management.
• Knowledge of health care delivery systems and payer policies.
• Ability to mentor junior case managers and provide guidance.

Responsibilities

• Manage a caseload of members with complex health needs and develop care plans.
• Coordinate services and monitor progress to achieve quality outcomes.
• Advocate for members and ensure compliance with policies and regulatory requirements.
• Document activities and maintain accurate records across systems.
• Collaborate with physicians, providers and care-team members to implement plans.

Skills

Clinical assessment

Care planning

Leadership

Advocacy

MS Office & EHR

Healthcare systems knowledge

Education

High School/GED

Bachelors in Nursing

Tools

Microsoft Office

EHR systems

Case management software

Job description

Job Summary

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.

Company

Highmark Inc.

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.

Essential 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.
• Evaluate the effectiveness of interventions and services.
• 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.
• Other duties as assigned or requested.

Experience

Required

• 5 years in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience.

Preferred

• Specialty specific clinical experience (e.g., Oncology, Transplant, Maternity, NICU, Pediatric)
• Experience working with the healthcare needs of diverse populations
• Experience demonstrating understanding of importance of culture competency in addressing targeted populations
• Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing, or dialectical behavior therapy (DBT)

Skills

• Expertise in clinical assessment and care planning.
• Strong leadership and mentoring skills.
• Excellent negotiation and advocacy skills.
• Proficiency in using Microsoft suite of applications, case management software and electronic health records.
• Strong understanding of healthcare systems and case management principles.

Education

Required

• High School/GED

Preferred

• Bachelors in Nursing.

Licenses or Certifications

Required

• 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. Incumbents in the role as of August 2026 are exempt from this requirement.

Preferred

• Certification in clinical area of expertise (e.g., OCN, CPN, CPON, CNN, CCTC, CPHQ).

Language (Other Than English)

• None.

Travel Required

• Less than 25%

Physical, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

• Office-Based or Remote Position

Physical Work Site Required

• Occasionally

Disclaimer

The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. 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.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. 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.

Pay Range Minimum

$79,300.00

Pay Range Maximum

$127,100.00

Discrimination Policy

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.

Accessibility & Contact

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.

For accommodation requests, please contact HR Services Online at [e-mail]

California Consumer Privacy Act Employees, Contractors, and Applicants Notice