Complex Case Manager RN - Specialty Pediatrics (Remote)

Company
Highmark Inc.

Job Summary
This position 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, using data and analytics in conjunction with professional clinical judgement, identifies the right clinical intervention for each member. Supported by a multidisciplinary team, the incumbent refers members to appropriate resources and manages an active case load of members enrolled in case management. The incumbent conducts outreach, develops care plans, encourages behavior changes, removes barriers, coordinates care, and identifies resources to help members achieve 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 a specified panel of members by performing ongoing assessment of health management needs, identifying appropriate clinical interventions, and triaging members to additional resources.

For the assigned case load, create care plans that address identified needs, remove barriers to care, identify resources, and conduct activities to improve health outcomes; care plans include both long‑term and short‑term goals and regular contacts for reassessment.

Ensure targeted percentage of member goal achievement and other patient outcomes are achieved.

Document all activities in compliance with business process requirements, regulatory requirements, and accreditation standards.

Maintain current knowledge and adhere to CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management, including those published by CMSA and/or ACMA.

Perform other duties as assigned or requested.

Education
Required : High School Diploma/GED

Preferred : Bachelors Degree in Nursing

Experience
Required : 7 years of clinical, case‑management, disease/condition‑management, provider operations, or health insurance experience.

Preferred :

Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing, or dialectical behavior therapy (DBT).

Experience working with diverse populations.

Understanding of the importance of cultural competency.

Licenses and Certifications
Required : Current State of PA RN licensure or current multi‑state licensure through eNLC (or WV/DE/NY). Other RN licenses, if applicable, must be obtained within the first 6 months.

Preferred : Certification in Case Management

Skills

Written and verbal presentation, negotiation, and influencing skills with respect and compassion.

Broad knowledge of disease processes.

Understanding of healthcare costs and the broader service delivery system.

Proficiency in MS Excel and strong analytic skills to interpret, evaluate, and act on clinical and financial data.

Excellent interpersonal and consensus‑building skills, working with colleagues at all levels.

Ability to work in a high‑performing team environment that requires flexibility.

Demonstrated ability to manage multiple priorities in a fast‑paced environment; strong organizational, time‑management, and project‑management skills.

Self‑directed, self‑starter, able to work with indirect supervision and moderate autonomy.

Language Requirement (Other than English)
None

Travel Requirement
0% – 25%

Physical, Mental Demands and Working Conditions
Office‑Based.

Heavy lifting: up to 10 lbs (rarely), 10–25 lbs (rarely), 25–50 lbs (rarely).

Pay Range
Minimum: $72,700.00

Maximum: $116,600.00

EEO Statement
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.

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