Senior Case Manager RN - Transplant RN (Remote)

Highmark Health; Pennsylvania; Hybride; USD 79 000 - 127 000; Plein temps

Résumé du poste

Highmark Health in Pittsburgh, PA seeks a skilled Case Manager to provide comprehensive case management services to members, coordinating care, assessing needs, and developing care plans to promote quality outcomes and cost containment.

You will collaborate with physicians and healthcare teams, advocate for members, mentor junior staff, and ensure documentation complies with HIPAA and company policies. Minimum 5 years of relevant experience required; RN licensure preferred.

Qualifications

• 5 years in clinical, case/utilization management, and/or disease condition management experience.
• Transplant experience and diverse populations exposure preferred.
• CBT/MI/DBT training and experience preferred.

Responsabilités

• Manage a caseload of members with complex health needs.
• Develop and implement individualized care plans.
• Coordinate services with physicians, providers and the healthcare team.
• Monitor progress and adjust care plans as needed.
• Advocate for members to obtain appropriate services within contract benefits.
• Document activities in compliance with policies and regulations.
• Mentor lower-level Case Managers.
• Communicate clearly with healthcare professionals and members.

Connaissances

Clinical assessment

Care planning

Leadership

Negotiation

Advocacy

Microsoft Suite

EMR/EHR

Formation

High School/GED

Bachelor's in Nursing

Outils

Case management software

Electronic Health Records (EHR)

Microsoft Office

Description du poste

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.

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 Transplant specific clinical experience 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

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 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. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

EEO Statement

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 Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network.

Company Overview

Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.