Company :

Job Description :

JOB SUMMARY

This job implements effective complimentary utilization and case management strategies for an assigned member panel. Provides oversight over a specified panel of members that range in health status/severity and clinical needs; and assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent conducts outreach to members enrolled in case management including but is not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. Will work with providers to insure quality and appropriate care is being delivered in a timely manner.

ESSENTIAL RESPONSIBILITIES

• Maintain oversight over specified panel of 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.
• Implement care management review processes that are consistent with established industry, corporate, state, and federal law standards and are within the care managers professional discipline.
• For assigned case load, 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.
• Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.
Other duties as assigned.

EDUCATION

Required

Substitutions

Preferred

• Bachelor's Degree in Nursing

EXPERIENCE

Required

• 7 years in any combination of clinical, case/utilization management and/or disease/condition management experience, or provider operations and/or health insurance experience
1 year in a clinical setting

Preferred

• 5 years in UM/CM/QA/Managed Care
• 1 year in advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT)
1 year working with the healthcare needs of diverse population and understanding of the importance of cultural competency in addressing targeted populations

LICENSES or CERTIFICATIONS

Required

• Current RN state licensure required. Additional specific state licensure(s) may be required depending on where clinical care is being provided.

Preferred

• Certification in utilization management or a related field
• Certification in Case Management

SKILLS

• Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion
• Broad knowledge of disease processes
• 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
• Understanding of healthcare costs and the broader healthcare service delivery system
• 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

Language (Other than English):

None

Travel Requirement:

0% - 25%

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

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 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.

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 Companys Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employees responsibility to comply with the companys 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.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidates qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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, age, 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, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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