[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
• 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

Company Description

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.

This position 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.