This job works directly with providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted in relation to quality and care costs. The incumbent could work in a physician’s office, visit physician practices on a routine basis, work within a hospital setting and/or visit the member’s home. This job directly helps members with the highest risk scores to coordinate care and navigate the healthcare system by recommending and/or implementing interventions related to the improvement of medical care and costs.
- Conduct member-facing clinical assessments that address the health and wellness needs of the members with the highest risk scores using a broad set of clinical and motivational interviewing skills with the goal of impacting members’ self-management skills and positive behavior changes which will ultimately positively impact member satisfaction and care costs.
- Serve as a subject matter expert to both internal and external sources (e.g. members, providers, regulatory agencies, UM and policy) to provide education, consultation, and training.
- Serve as a resource to guide, mentor, and counsel others in regard to understanding the drivers of health care costs to improve member outcomes related to Plan benefits and resources.
- Collaborate, coordinate, and communicate with the member’s treating provider(s) in more complex clinical situations requiring clinical and psychosocial intervention.
- Develop and implement case-or condition-specific plans of care and/or intervention plans, as needed, that can become a part of the member’s medical record to establish short and long-term goals.
- Establish a plan for regular contact (face-to-face as often as possible) with each member and/or provider to monitor progress toward goals, provide additional education and evaluate the need for modification or change in the plan of care.
- Proactively incorporate lifestyle improvement opportunities and preventive care into member interactions and coaching
- Collaborate with the appropriate individuals to offer solutions to refine and improve existing practices or participates in developing performance improvement processes that will enhance member outcomes and operational performance/excellence as well support all strategic initiatives including Health Care Reform and STARS initiatives.
- Work with providers related to performance measures and activities to educate and influence the behavior of members and providers.
- Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
- Other duties as assigned.
- Bachelor's Degree in Nursing
- 5 - 7 years of Case Management Experience, Clinical Practice Experience, or Disease/Condition Management Experience
LICENSES OR CERTIFICATIONS
- ACM Certification (Accredited Case Manager)
- Certified Chronic Care Manager (CCM)
- Microsoft Excel
- Communication Skills
- Self Starter
- Health Education
- Healthcare Industry
- Friendly Personality
- Data Analysis
- Statistical Analysis
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