Case Manager, RN
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Job Description
Remote Case Manager RN for Highmark health insurance, assessing members and coordinating individualized care plans. Managing utilization, referrals, outcomes, and cost-effective healthcare delivery.
Responsibilities:
- Provide comprehensive case management services to members
- Manage a caseload of members with moderate complexity health needs
- Assess members’ health status, needs, and available resources
- Develop individualized care plans with members, physicians, and other healthcare providers
- Implement and coordinate care plans and ensure access to appropriate services and resources
- Coordinate referrals to specialists and community resources
- Monitor member progress and adjust care plans as needed
- Evaluate the effectiveness of interventions and services
- Act as an advocate and liaison to meet members’ individual healthcare needs
- Collaborate and communicate with physicians, providers, coworkers, and healthcare team members
- Document activities in compliance with business processes, company policies, regulatory requirements, and accreditation standards
- Identify potential cost savings, quality improvements, and workflow efficiencies
- Detect, resolve, and prevent improper utilization of member benefits
- Perform other duties as assigned or requested
Requirements:
- High School Diploma/GED
- 3 years in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience
- Current State of PA RN licensure OR current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or NY
- Other RN license(s), if applicable, must be obtained within the first 6 months of employment
- Proficiency in using Microsoft suite of applications, case management software and electronic health records
- Strong assessment and care planning skills
- Understanding of healthcare systems and case management principles
- Ability to work independently and as part of a team
- Preferred: Bachelor's Degree in Nursing
- Preferred: Experience working with the healthcare needs of diverse populations
- Preferred: Experience demonstrating understanding of the importance of cultural competency in addressing targeted populations
- Language requirement other than English: None
- Travel requirement: 0% - 25%
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