Unknown Company is hiring a Medical Case Manager

Highmark Inc. is seeking a Medical Case Manager (Triage Clinical Nurse Care Coordinator) to ensure members with complex medical, behavioral health, and social determinants of health needs receive timely access to high-quality, cost-effective care. You will be responsible for triaging member assignments based on clinical and social needs, facilitating holistic assessments, and coordinating services.

What You'll Do

• Triage member assignments based on comprehensive assessment of clinical and social needs.
• Match members with the most appropriate care team member.
• Facilitate holistic assessment of member needs, care planning, and coordination of services.
• Advocate for optimal care plans and staff assignments through collaboration with stakeholders.
• Communicate effectively while performing customer telephonic interviewing and with external contacts.
• Interact with Case Management Specialists, Management Team, Physician Advisors, and interdepartmental contacts.
• Maintain knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States.
• Educate members to enhance understanding of illness/disease impact and improve care plan adherence.
• Collaborate with Primary Care Physicians, Medical Specialists, Home Health, and other healthcare providers to coordinate care.
• Collect member medical information from providers and internal records to determine unmet needs.
• Work independently to identify, define, and resolve member problems.
• Develop an individualized plan of care designed to meet specific member needs.
• Continually assess and monitor member progress toward goals and re-adjust goals when indicated.
• Maintain knowledge of available resources for addressing member needs.
• Consider benefit design and cost benefit analysis when planning interventions.
• Communicate and collaborate with other payers for care management and benefit coordination.
• Maintain knowledge of available community resources.
• Coordinate with community organizations/agencies to identify additional resources.
• Work within a Team Environment.
• Attend and participate in required meetings, staff meetings, internal Rounds, and in-services.
• Participate in departmental and/or organizational work and quality initiative teams.
• Case collaborate with peers, Case Management Specialists, Management Team, Physician Advisors, and interdepartmental contacts.
• Participate in interagency and/or interdisciplinary team meetings to facilitate coordination of care.
• Foster effective work relationships through conflict resolution and constructive feedback.
• Attend internal and external continuing education forums to enhance clinical skills.
• Educate health team colleagues on the role of Case Management and member needs.

What We're Looking For

• Bachelor’s degree in nursing OR RN certification in lieu of bachelor's degree OR Master’s degree in Social Work, Counseling, Education, or related field AND 3 years' experience in Acute or Managed Care/ experience with Medicaid or Medicare populations.
• OR Bachelor’s degree in Social Work with five years’ experience in Acute or Managed Care/ experience with Medicaid or Medicare populations.
• Licensed Social Worker (LSW)-Non-Specific - State (OR) Registered Nurse - Non-Specific (OR) Licensed Professional Counselor (LPC) – Non-Specific State (OR) Licensed Bachelors Social Worker (LBSW).

Nice to Have

• Demonstrated experience and expertise in multiple areas of healthcare: pediatrics, maternity, behavioral health, chronic conditions, substance use, and transition of care.
• 3 years of experience in working in Acute Care/Managed Care/Medicaid and Medicare populations.
• Case Management Certification.
• Proficiency in Electronic Health Records (EHR).
• Proficient in Microsoft Office Suite, with advanced Excel skills.
• Critical Thinking and Problem-Solving skills.

Technical Stack

• Electronic Health Records (EHR)
• Microsoft Office Suite

Team & Environment

Collaborates with Case Management Specialists, Management Team, Physician Advisors, interdepartmental contacts, and external stakeholders.

Benefits & Compensation

• Salary: $57,700.00 - $107,800.00

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.