Care Manager RN (Remote)

About the Role

This position serves as a strategic partner in Highmark's utilization management strategy, focusing on the effective delivery of healthcare services. The role is designed to ensure resources are utilized appropriately while identifying opportunities to enhance member health outcomes through proactive interventions.

You will act as a bridge between clinical care and administrative oversight, reviewing the appropriateness of healthcare services against established industry and corporate standards. A key part of your day involves analyzing qualitative and quantitative data to develop strategies that improve both provider performance and member satisfaction. You will educate providers and members on a proactive basis, responding to inquiries and offering alternatives or interventions when necessary.

The role requires a collaborative approach to care management. You will identify members who could benefit from Health Coaching or case management and employ interventions that maximize their healthcare outcomes. By developing and sustaining positive relationships with internal and external customers, you will help streamline processes and build strong network rapport.

Compliance and Ethics

This position operates within a strict framework of ethical principles and regulatory compliance. You will function in accordance with applicable state and federal laws, ensuring that all care management reviews adhere to accepted criteria and medical policies. Protecting the member's right to privacy is paramount; information is shared only when relevant to the member's care and within legal boundaries.

As a Highmark employee, you will adhere to the Code of Business Conduct and all company policies. This includes strict compliance with the Health Insurance Portability and Accountability Act (HIPAA) and all data security guidelines regarding covered information and confidential customer data.

Equal Opportunity Employer

Highmark Health and its affiliates are committed to a diverse workforce and prohibit discrimination against qualified individuals based on protected status, including veterans and individuals with disabilities. We endeavor to make our application process accessible to all users. If you require accommodation during the application process, please contact HR Services Online at HRServices@highmarkhealth.org.