Complex Case Manager RN (Remote)

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. 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, state, local, 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. Other duties as assigned or requested. EDUCATION Required High School Diploma/GED Substitutions None Preferred Bachelor's Degree in Nursing EXPERIENCE Required 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience Preferred 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 LICENSES AND CERTIFICATIONS Required 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. Preferred Certification in Case Management SKILLS Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion Broad knowledge of disease processes Understanding of healthcare costs and the broader healthcare service delivery system Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization Ability to work in a high performing team environment that requires flexibility Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy LANGUAGE REQUIREMENT (Other than English) None TRAVEL REQUIREMENT 0% - 25% PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS Position Type Office-Based Teaches/Trains others regularly Rarely Travels regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products/services (Sales employees) Does Not Apply Physical Work Site Required No Lifting: up to 10 pounds Rarely Lifting: 10 to 25 pounds Rarely Lifting: 25 to 50 pounds Rarely Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job. Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements. Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets. Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at View email address on click.appcast.io California Consumer Privacy Act Employees, Contractors, and Applicants Notice #J-18808-Ljbffr