Senior Case Manager RN - Transplant RN (Remote)

Highmark Health; Springfield (IL); Hybrid; USD 114,000 - 140,000; Full time

Job summary

Highmark Health is seeking a Case Manager to provide comprehensive, outcomes-focused care management for members with complex health needs. You will assess, plan, coordinate, and monitor services with physicians and the health team to deliver quality, cost-effective care.

Required: BSN and active RN licensure, 5+ years in case management, and CCM certification due within 36 months. Experience with CBT/MI/DBT and EMR systems is preferred; travel may be necessary.

Qualifications

• 5 years of clinical/case management or related health operations experience.
• Experience with diverse populations.
• Advanced training in CBT, motivational interviewing, or DBT.
• Expertise in clinical assessment and care planning.
• Proficiency with Microsoft Office, case management software, and EMR.
• Strong understanding of healthcare systems and case management principles.
• BSN and RN licensure or multi-state eNLC.
• CCM certification due within 36 months of hire (OCN, CPN, CPON, CNN, CCTC, CPHQ).
• Language skills beyond English as applicable.

Responsibilities

• Manage a caseload of members with complex health needs.
• Conduct comprehensive assessments and develop complex care plans.
• Assess health status, needs, and resources.
• Develop individualized care plans with members, physicians, and providers.
• Implement and coordinate care plans ensuring access to services.
• Monitor progress and adjust plans as needed.
• Advocate and liaison to meet members’ health care needs.
• Collaborate with physicians and health care team to execute the plan.
• Ensure documentation complies with policies and standards.
• Mentor lower-level Case Managers.
• Provide clinical expertise and problem-solving support.

Skills

Case management

Clinical assessment

Care planning

Communication

Interprofessional collaboration

CBT/MI/DBT training

Microsoft Office

EMR / EHR

Team mentorship

Education

Bachelor’s in Nursing (BSN)

RN licensure (State)

eNLC multi-state licensure

CCM certification (within 36 months)

Tools

Case management software

Electronic Health Records (EHR)

Microsoft Office

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.

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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