Embedded Case Manager RN

Job ID: J119480
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: May 18, 2018

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Description

JOB SUMMARY

This job owns and conducts oversight over a specified panel of inpatient members that range in health status/severity and clinical need.  The incumbent assesses health management and psychosocial needs of the assigned member panel and utilizes data/analytics, in conjunction with clinical judgement and hospital care team insight, to identify the right clinical intervention for each member and support the discharge planning process.  The incumbent supports multiple teams and processes from both the Provider and Health Plan.  The incumbent works within facility processes to coordinate, connect, and collaborate in order to identify and address barriers, eliminate redundancies, streamline inefficiencies and improve member satisfaction and outcomes. The incumbent serves as an embedded resource to gather relevant information, assist in discharge planning options, help resolve barriers and placement issues, and refer members to appropriate resources post discharge.   The incumbent conducts face to face member visits as needed for the purposes of providing real-time support for utilization and case management needs, participating in discharge planning and transitions of care,  initiating plans of care and making introductions and referrals to Highmark programs and resources.  The incumbent monitors, improves, and maintains quality outcomes (clinical, financial and functional) for the specified panel with the primary objective to improve member experience by strengthening enterprise utilization and case management. 

ESSENTIAL RESPONSIBILITIES

  • Coordinate with current processes to assure needs of the patient/member are met on all levels, teams are aligned, hand offs are seamless and work is timely and efficient.  
  • Understand the clinical and psychosocial situation of the member and serve as a liaison to the Highmark Integrated Care Team and Inpatient Team in obtaining any outstanding information about the member.
  • Communicate with the hospital care teams to identify, monitor and work toward timely resolution of transition of care challenges.
  • Participate in daily discharge planning discussions to inform of discharge options, support the most appropriate discharge plan, help resolve barriers and placement issues, assure the right resources are in place prior to discharge and assist with post acute transitions.
  • Introduce the member to the Highmark case manager or ECCM care coordinator who will support post-discharge needs.  Coordinate calls, maximize resources and referrals and share appropriate content.
  • Screen the daily census for all lines of business and all Highmark members to identify high cost admissions, readmissions and other high risk members; prioritize.
  • Other duties as assigned or requested.

EDUCATION

Required

  • Bachelor's Degree in Nursing

EXPERIENCE

Required

  • 5 - 7 years in Clinical Services, Case Management, Disease/Condition Management, Provider Services or the Health Insurance Industry

LICENSES AND CERTIFICATIONS

Required

  • Registered Nurse (RN License in PA, WV, and DE is required.  At least one of these state licensures must be active at the time of hire.  Others must be obtained within the first 6 months of employment.  Additional state licensure may be required.)

SKILLS

  • Written & Oral Presentation Skills
  • Negotiation

Language (Other than English)

None 

Travel Required

0%  - 25%


PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Physical work site required 

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

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.

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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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 number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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