Highmark Inc. is hiring a Care Manager RN to implement effective utilization management strategies for our members in Delaware. In this remote role, you will review the appropriateness of healthcare services, apply criteria to ensure proper resource utilization, and identify opportunities for referral to Health Coaching or case management. You'll analyze data to improve provider performance and member satisfaction while functioning within all applicable state and federal laws.
What You'll Do
- Implement care management review processes consistent with established industry and corporate standards.
- Function in accordance with applicable state and federal laws and regulatory compliance.
- Promote quality and efficiency in the delivery of care management services.
- Respect the member’s right to privacy, sharing only information relevant to their care.
- Practice within the scope of ethical principles.
- Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching or case management.
- Employ collaborative interventions to maximize the member’s health care outcomes.
- Educate professional and facility providers to streamline processes and develop network relationships.
- Develop and sustain positive working relationships with internal and external customers.
- Utilize outcomes data to improve ongoing care management services.
What We're Looking For
- Bachelor's Degree in Nursing or relevant experience and/or education as determined by the company in lieu of a degree.
- 3 years of related, progressive clinical experience in the area of specialization.
- Experience in a Clinical Setting.
- Current State of PA RN licensure OR current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
- Delaware RN license must be obtained within the first 6 months of employment, unless the home state license is part of the compact.
Nice to Have
- Master's Degree in Nursing.
- Experience in UM/CM/QA/Managed Care.
- Certification in Utilization Management or a related field.
Work Mode
This is a remote position, and candidates must be located in Delaware.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
