Highmark Inc.
ComplexCaseManagerRN(Remote)
Neural analysis suggests this role is
optimal for Senior candidates.
“Complex Case Manager RN (Remote) at Highmark Inc.. Skills: Case management, Clinical judgment, Care plan development. Maintain oversight over specified panel of members. Perform ongoing assessment of members’ health management needs”
What You'll Achieve.
Monitor, improve and maintain quality outcomes (clinical, financial and functional); Ensure targeted percentage of patient goal achievement; Ensure other patient outcomes, as applicable, are achieved
Industry & Context.
Analytic skills; Interpret, evaluate and act on clinical and financial data; Analysis of statistical data
Travel 0% - 25%, Compliance with HIPAA, Compliance with data security guidelines, Compliance with company's Code of Business Conduct
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.
Maintain oversight over specified panel of members
Perform ongoing assessment of members’ health management needs
Identify right clinical interventions
Triage members to appropriate resources
Create care plans for assigned caseload
Address members’ identified needs
Remove barriers to care
Identify resources for members
Improve health outcomes
Develop long and short term goals
Plan regular contacts for re-assessment
Ensure targeted percentage of patient goal achievement
Ensure all activities are documented
Conduct outreach to members enrolled in case management
Manage active case load of members
How You'll Work.
Team & Collaboration
Work with a variety of internal and external colleagues from all levels of an organization; Work in a high performing team environment
Communication Scope
Written and verbal presentation skills; Positively influencing others; 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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