Care Manager Behavioral Health - Part Time (Weekends) Remote

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

Fully Remote - Part Time - Weekends Required. 

This job implements the effective utilization management strategies including:  review of appropriateness of health care services, application of criteria to assure 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.  Effectively 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

• High School Diploma/GED with RN license or Master's Degree if licensed behavioral health professional

Substitutions

• None

Preferred

• Bachelor’s degree in Nursing

EXPERIENCE

Required

• 3 - 5 years of post licensure experience in a combination of Behavioral Health Clinical, Case Management and/or Condition Management
• Experience in a clinical setting

Preferred 

• Certification in utilization management or a related field
• Experience in UM/CM/QA/Managed Care

LICENSES AND CERTIFICATIONS

Required (any of the following)

• Licensed Social Worker (LSW)
• Licensed Clinical Social Worker (LCSW)
• Licensed Professional Counselor (LPC)
• Licensed Marriage and Family Therapist (LMFT)
• Licensed Behavior Specialist
• Registered Nurse.

Preferred

• None

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

Language (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

Rarely

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

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds