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 and applying established criteria to guide decision-making. A key part of your day involves analyzing both qualitative and quantitative data to develop strategies that improve provider performance and member satisfaction. You will also be responsible for educating providers and members on a proactive basis, responding to customer inquiries, and offering targeted interventions or alternatives when necessary.

The role requires a collaborative approach, fostering positive working relationships with internal and external customers, as well as professional and facility providers. By identifying members who could benefit from Health Coaching or case management, you will help streamline care processes and maximize health outcomes within the framework of ethical principles and regulatory compliance.