Care Manager RN at Highmark Health

$50,200 - $90,300/Yr

Unclassified - Honolulu, HI

Full-time - Mid Level

Remote - Honolulu, HI

About the position

The position at Highmark Inc. involves implementing effective utilization management strategies that include reviewing the appropriateness of healthcare services, applying criteria to ensure appropriate resource utilization, and identifying opportunities for referral to Health Coaching or case management. The role requires monitoring and analyzing the delivery of healthcare services, educating both providers and members proactively, and analyzing qualitative and quantitative data to develop strategies aimed at improving provider performance and member satisfaction. Additionally, the position involves responding to customer inquiries and offering interventions or alternatives as necessary. In this role, the care manager will implement care management review processes that align with established industry and corporate standards while adhering to applicable state and federal laws and regulatory compliance. The care manager will be responsible for promoting quality and efficiency in the delivery of care management services, respecting the member's right to privacy, and practicing within the scope of ethical principles. The position also requires identifying and referring members whose healthcare outcomes could be enhanced through Health Coaching or case management interventions, employing collaborative interventions to maximize healthcare outcomes, and educating professional and facility providers to streamline processes and develop network rapport. The care manager will utilize outcomes data to improve ongoing care management services and will be expected to perform other duties as assigned or requested. This position is remote, allowing for flexibility in work arrangements while maintaining a focus on delivering high-quality care management services.

Responsibilities

• Implement care management review processes consistent with established industry and corporate standards.
• Function in accordance with applicable state and federal laws and regulatory compliance.
• Implement care management reviews according to accepted criteria and medical policies.
• Promote quality and efficiency in care management services delivery.
• Respect the member's right to privacy, sharing only relevant information.
• Practice within the scope of ethical principles.
• Identify and refer members for Health Coaching or case management interventions.
• Employ collaborative interventions to maximize member healthcare outcomes.
• Educate providers and vendors to streamline processes and develop relationships.
• Develop and sustain positive working relationships with internal and external customers.
• Utilize outcomes data to improve ongoing care management services.
• Perform other duties as assigned or requested.

Requirements

• 3 years of related, progressive clinical experience in the area of specialization.
• Experience in a clinical setting.
• Current RN state licensure required.
• Additional specific state licensure(s) may be required depending on where clinical care is provided.

Nice-to-haves

• Bachelor's Degree in Nursing
• Experience in UM/CM/QA/Managed Care
• Certification in utilization management or a related field.