Senior Case Manager RN

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 complex health needs, requiring advanced clinical knowledge.

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Conduct comprehensive assessments and develop complex care plans.

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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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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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Provide guidance and mentorship to lower-level Case Managers.

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Serve as a resource for clinical expertise and problem-solving.

- Other duties as assigned or requested.

EXPERIENCE

Required
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5 years in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience.

Preferred

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Specialty specific clinical experience (e.g., Oncology, Transplant, Maternity, NICU, Pediatric)

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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

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Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing, or dialectical behavior therapy (DBT)

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SKILLS

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Expertise in clinical assessment and care planning.

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Strong leadership and mentoring skills.

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Excellent negotiation and advocacy skills.

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

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Strong understanding of healthcare systems and case management principles.

EDUCATION

Required
- High School/GED

Preferred
- Bachelors in Nursing.

LICENSES or CERTIFICATIONS

Required

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Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)

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Certified Case Manager (CCM) certification must be obtained within 36 months of hire.Incumbents in the role as of August 2026 are exempt from this requirement.

Preferred
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Certification in clinical area of expertise (e.g., OCN, CPN, CPON, CNN, CCTC, CPHQ).

Language (Other than English):
- None.

Travel Required:
- Less than 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
- Office-Based or Remote Position

Physical work site required
- Occasionally

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this