Care Manager RN – (Remote)

About Highmarkhealth

Highmark Inc. is dedicated to implementing effective utilization management strategies to ensure quality healthcare services.

Job Summary

This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

Key Responsibilities

• Implement care management review processes that are consistent with established industry and corporate standards.
• Function in accordance with applicable state, federal laws and regulatory compliance.
• Promote quality and efficiency in the delivery of care management services.
• Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
• Educate professional and facility providers and vendors for the purpose of streamlining and improving processes.
• Utilize outcomes data to improve ongoing care management services.

Requirements

• Current RN state licensure required.
• 3 years of related, progressive clinical experience in the area of specialization.
• Bachelor’s Degree in Nursing preferred.
• Experience in UM/CM/QA/Managed Care preferred.