[Hiring] Care Manager RN - Utilization Management @Highmark Health

Role Description

This job implements effective utilization management strategies including:

• Review of appropriateness of health care services
• Application of criteria to ensure appropriate resource utilization
• Identification of opportunities for referral to a Health Coach/case management
• Identification and resolution of quality issues

Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

Qualifications

• Preferred: Bachelor’s Degree in Nursing

Requirements

• Required: 3 years of related, progressive clinical experience in the area of specialization
• Required: Experience in a clinical setting
• Preferred: Experience in UM/CM/QA/Managed Care
• Preferred: Medical/Surgical experience
• Preferred: Utilization Management (UM) or (UR) Utilization Review experience
• Required: Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
• Preferred: Certification in utilization management or a related field

Benefits

• Working knowledge of pertinent regulatory and compliance guidelines and medical policies
• Ability to multi-task and perform in a fast-paced and often intense environment
• Excellent written and verbal communication skills
• Ability to analyze data, measure outcomes, and develop action plans
• Be enthusiastic, innovative, and flexible
• Be a team player who possesses strong analytical and organizational skills
• Demonstrated ability to prioritize work demands and meet deadlines
• Excellent computer and software knowledge and skills

Physical, Mental Demands and Working Conditions

• Position Type: Office-Based
• Teaches/trains others regularly: Occasionally
• Travel regularly from the office to various work sites or from site-to-site: Does Not Apply
• Works primarily out-of-the office selling products/services (sales employees): Does Not Apply
• Physical work site required: Yes
• Lifting: up to 10 pounds: Constantly
• Lifting: 10 to 25 pounds: Occasionally
• Lifting: 25 to 50 pounds: Rarely, Occasionally