Care Manager RN - UM (Full-Time) Weekends (Remote)

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This is a full-time REMOTE position requiring weekend availability (Saturday and Sunday) in addition to three weekdays.

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.

ESSENTIAL RESPONSIBILITIES

• Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.

• Function in accordance with applicable state, federal laws and regulatory compliance.

• Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.

• Promote quality and efficiency in the delivery of care management services.

• Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws.

• Practice within the scope of ethical principles.

• Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.

• Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes. Is familiar with the various care options and provider resources available to the member.

• Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.

• Develop and sustain positive working relationships with internal and external customers.

• Utilize outcomes data to improve ongoing care management services.

• Other duties as assigned or requested

EDUCATION

Required

• None

Preferred

• Bachelor’s Degree in Nursing

EXPERIENCE

Required

• 3 years of related, progressive clinical experience in the area of specialization

• Experience in a clinical setting

Preferred

• 3 years RN experience

• RN Case Management, Care Management

• Experience in UM/CM/QA/Managed Care

• Experience with acute inpatient and post-acute

• Experience with skilled nursing, inpatient Rehab

LICENSES AND CERTIFICATIONS

Required

• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Additional specific state licensure(s) may be required depending on where clinical care is being provided.

Preferred

• Certification in Utilization Management or a related field

SKILLS

• Working knowledge of pertinent regulatory and compliance guidelines and medical policies

• Ability to multi task and perform in a fast paced and often intense environment

• Excellent written and verbal communication skills

• Ability to analyze data, measure outcomes, and develop action plans

• Be enthusiastic, innovative, and flexible

• Be a team player who possesses strong analytical and organizational skills

• Demonstrated ability to prioritize work demands and meet deadlines

• Excellent computer and software knowledge and skills

Languages (Other than English)

None

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches/trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (sales employees)

Does Not Apply

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly