Nurse Case Manager - RN

Job ID: J122791
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at:

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Description

JOB SUMMARY

This job is the primary clinician managing members wide range in health status/severity and clinical needs in either a case management or condition (disease) management program.  The incumbent will be responsible for assessing health management needs of the assigned members and utilizing data/analytics present in FEP Direct Care Coordination Portal (HEDIS, pharmacy, appropriate site of service, high cost alerts, and member wellness profile to identify the member’s health-related conditions or serious medical issues.)   The incumbent will be supported by an internal multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. The incumbent is responsible for interacting with external vendors (Nurse line, Rare Disease CM vendor), other Blue plans, and group – Blue Cross Blue Shield Association (BCBSA)  Federal Employee Program Director’s applications and on occasions, the FEP DO Clinical Account Manager in care coordination.  

ESSENTIAL RESPONSIBILITIES

  • Maintain oversight over of Federal Employee 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.
  •  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. for assigned case load.
  • 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 under Highmark and the BCBSA guidelines.
  • 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.​
  • Function as a primary educator for members who have specific health conditions for which the organization has formal disease management programs. Across the continuum of services the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making to optimize their clinical outcomes.    Identify opportunities for plan and member savings through utilization of network providers, alternative clinical strategies or benefit options.
  • Other duties as assigned.

QUALIFICATIONS

Minimum

  • High School/GED
  • 5 - 7 years Clinical Services or 5 - 7 yearsCase Management to include 5 - 7 years Disease/Condition Management or 5 - 7 years Health Insurance Industry

  • Registerd Nurse
  • Certification in Case Management (CCM) - or ability to obtain a CCM within 2 years of hire.

Preferred

  • Bachelor's Degree in Nursing

SKILLS

  • Oral & Written Communication Skills
  • Influence and Persuasion
  • Healthcare
  • Analytical and Logical Reasoning/Thinking
  • Flexibility
  • Prioritizing
  • Time Management

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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