Care Manager RN - UM (Full-Time) Weekends

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

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

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

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

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

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

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Practice within the scope of ethical principles.

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

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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.

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

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

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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

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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

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Experience with acute inpatient and post-acute

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Experience with skilled nursing, inpatient Rehab

LICENSES AND CERTIFICATIONS

Required
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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
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Certification in Utilization Management or a related field

SKILLS

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Working knowledge of pertinent regulatory and compliance guidelines and medical policies

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

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Excellent written and verbal communication skills

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

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Be enthusiastic, innovative, and flexible

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Be a team player who possesses strong analytical and organizational skills

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Demonstrated ability to prioritize work demands and meet deadlines

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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 product