Senior Case Manager RN - Transplant RN (Remote)

Highmark Health; Bastrop (LA); Remote; USD 114,000 - 140,000; Full time

Job summary

Highmark Health is seeking a Case Manager to deliver comprehensive, cost-conscious care management for members with complex needs. You will assess, plan, implement, and monitor care while coordinating with physicians and providers to optimize outcomes.

The role emphasizes adherence to HIPAA, use of EHRs, and ongoing professional development, including supervision of junior staff and adherence to contract benefits.

Qualifications

• At least five years in clinical or utilization management roles with health insurance experience.
• Experience with diverse populations and healthcare needs.
• Advanced training in CBT, motivational interviewing, or DBT.
• Expertise in clinical assessment and care planning.
• Proficiency with Microsoft Office, case management software and EHR systems.

Responsibilities

• Manage a caseload of members with complex health needs and coordinate care.
• Conduct comprehensive assessments and develop complex care plans.
• Implement, monitor and adjust care plans to achieve goals.
• Collaborate with physicians and providers to ensure access to services.
• Document activities in compliance with policies and regulations.
• Provide guidance and mentorship to lower-level Case Managers.

Skills

Clinical knowledge

Communication

Documentation

Mentorship

Problem solving

Microsoft Office

Case management software

Electronic Health Records

Education

Bachelor's in Nursing

RN licensure

CCM certification within 36 months

eNLC multi-state licensure

Tools

Case management software

Microsoft Office

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.

• 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.

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

• 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).

• 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.

All employees must comply with 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.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice