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About the Role
This role provides 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 healthcare costs.
Responsibilities
- Manage a caseload of members with moderate complexity health needs.
- Assess members’ health status, needs, and available resources.
- Develop individualized care plans in collaboration with members, physicians, and other healthcare providers.
- Implement and coordinate care plans, ensuring access to appropriate services and resources.
- Develop and implement care plans with guidance from senior staff.
- Coordinate referrals to specialists and community resources.
- Monitor member progress toward goals and adjust care plans as needed.
- Evaluate the effectiveness of interventions and services.
- 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.
- 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.
- Ensure all activities are documented and conducted in compliance with applicable business process requirements, company policies, regulatory requirements and accreditation standards.
- Identify areas for potential cost savings, quality improvement and workflow efficiencies.
- 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 is required.
- Other RN license(s), if applicable, must be obtained within the first 6 months of employment.
- Adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
- Complies with HIPAA as described in the Notice of Privacy Practices and Privacy Policies and Procedures.
- Complies with all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
- Complies with the company’s Code of Business Conduct, including adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Skills
- Strong assessment and care planning skills.
- Ability to work independently and as part of a team.
- Proficiency in using Microsoft suite of applications, case management software and electronic health records.
- Understanding of healthcare systems and case management principles.
Location
- Office-Based
Work Type
- Office-Based
Experience Level
- 3 years of experience
Education Level
- High School Diploma/GED
- Bachelor's Degree in Nursing (Preferred)
Salary/Compensations
- $72,700.00 - $116,600.00
About the Company
- Highmark Inc.
Equal Opportunity
- 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.
- California Consumer Privacy Act Employees, Contractors, and Applicants Notice