Highmark Inc.
ComplexCaseManagerRN(Remote)
Neural analysis suggests this role is
optimal for Mid+ candidates.
“Complex Case Manager RN (Remote) at Highmark Inc.. Skills: case management, clinical intervention, care plan development, outcome monitoring. primary ownership and oversight over a specified panel of members. assess health management needs of the assigned member panel”
Industry & Context.
analytic skills with ability to interpret, evaluate and act on clinical and financial data; analysis of statistical data
HIPAA, adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies, compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), compliance with all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy, compliance with the company’s Code of Business Conduct, adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements
What They're Looking For.
Must Have
High School Diploma/GED, 7 years of any combination of clinical, case management and/or disease/condition management experience, 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.
Nice to Have
Bachelor's Degree in Nursing, Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT), Experience working with the healthcare needs of diverse populations, Understanding of the importance of cultural competency in addressing targeted populations, Certification in Case Management
What You'll Do.
primary ownership and oversight over a specified panel of members
assess health management needs of the assigned member panel
utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member
refer members to appropriate multi-disciplinary resources
manage an active case load of members
conduct outreach to members enrolled in case management
developing a care plan
encouraging behavior changes
identifying and addressing barriers
helping members to coordinate care
identifying various resources to assist members in achieving their personal health goals
improves and maintains quality outcomes (clinical
financial and functional) for the specified panel of members
ongoing assessment of members’ health management needs
identifying the right clinical interventions to address member needs
triaging members to appropriate resources for additional support
create care plans to address members’ identified needs
remove barriers to care
conduct a number of other activities to help improve the health outcomes of care plans include both long and short term goals and plan of regular contacts for re-assessment
Ensure targeted percentage of patient goal achievement (i. e.
realization of member care plan)
and other patient outcomes
Ensure all activities are documented and conducted in compliance with applicable business process requirements
regulatory requirements and accreditation standards.
Maintain current knowledge and adheres to applicable CMS
and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA
as required by the organization.
How You'll Work.
Team & Collaboration
supported by a multi-disciplinary team; work with a variety of internal and external colleagues from all levels of an organization; Ability to work in a high performing team environment
Communication Scope
Written and verbal presentation skills; negotiation skills; positively influencing others with respect and compassion; interpersonal skills; consensus building skills
Process & Methodology
project management skills
Full Job Description
## **Company :** Highmark Inc. ## **Job Description :** **JOB SUMMARY** This job has primary ownership and oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members. **ESSENTIAL RESPONSIBILITIES** * Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support. * For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment. * Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved.
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