Medical Case Manager - Remote (Pennsylvania)

Company :
Highmark Inc. Job Description :
JOB SUMMARY

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.
ESSENTIAL RESPONSIBILITIES

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Manage a caseload of members with moderate complexity health needs.

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Assess members’ health status, needs, and available resources.

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Develop individualized care plans in collaboration with members, physicians, and other healthcare providers.

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Implement and coordinate care plans, ensuring access to appropriate services and resources.

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Develop and implement care plans with minimal guidance.

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Coordinate referrals to specialists and community resources.

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Monitor member progress toward goals and adjust care plans as needed.

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Evaluate the effectiveness of interventions and services.

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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.

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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.

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Ensure all activities are documented and conducted in compliance with applicable business process requirements, company policies, regulatory requirements and accreditation standards.

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Identify areas for potential cost savings, quality improvement and workflow efficiencies.

- Other duties as assigned or requested.

EXPERIENCE

Required
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3 years of experience in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience with RN licensure or a Master’s degree OR; 5 years’ experience with a Bachelor’s in Social Work

Preferred

- Telephonic experience

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Medicaid managed care and/or Medicare experience

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Experience working with the healthcare needs of diverse populations

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Experience demonstrating understanding of importance of culture competency in addressing targeted populations

SKILLS

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Strong assessment and care planning skills.

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Ability to work independently and as part of a team.

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Proficiency in using Microsoft office suite, case management software and electronic health records.

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Understanding of healthcare systems and case management principles

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Bilingual English/Spanish language skills preferred

EDUCATION

Required
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Bachelor’s degree in nursing or RN licensure or Master’s degree in Social Work, Counseling, or related field OR Bachelor’s degree in Social Work

Preferred
- None

LICENSES or CERTIFICATIONS

Required
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Licensed Social Worker (LSW)-Non-Specific - State (OR) Licensed Professional Counselor (LPC) - Non-Specific State (OR) Licensed Bachelors Social Worker (LBSW) (OR) Licensed Clinical Social Worker (LCSW) - Non-Specific (OR) Licensed Master Social Worker (LMSW) Non-Specific (OR) Licensed Graduate Social Worker (LGSW) (OR) Licensed Certified Social Worker (LCSW) (OR) Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Incumbents in the role prior to 1/1/25 who are not currently licensed must obtain licensure by 12/31/27.

Preferred
- Certified Case Manager (CCM)

Language (Other than English):
None
Travel Required:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CON