Care Manager RN

4 weeks ago


Charleston, West Virginia, United States Highmark Health Full time

Job Summary

This role is responsible for implementing effective utilization management strategies, including reviewing the appropriateness of healthcare services, applying criteria to ensure appropriate resource utilization, identifying opportunities for referral to a Health Coach/case management, and resolving quality issues.

The Care Manager RN will monitor and analyze the delivery of healthcare services, educate providers and members on a proactive basis, and analyze qualitative and quantitative data to develop strategies to improve provider performance/satisfaction and member satisfaction.

The ideal candidate will respond to customer inquiries, offer interventions and/or alternatives, and promote quality and efficiency in the delivery of care management services.

Essential Responsibilities

  • Implement care management review processes consistent with established industry and corporate standards.
  • Function in accordance with applicable state, federal laws, and regulatory compliance.
  • Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
  • Promote quality and efficiency in the delivery of care management services.
  • Respect the member's right to privacy, sharing only information relevant to the member's care and within the framework of applicable laws.
  • Practice within the scope of ethical principles.
  • Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
  • Employ collaborative interventions that focus, facilitate, and maximize the member's healthcare outcomes.
  • Educate professional and facility providers and vendors to streamline and improve processes, while developing network rapport and relationships.
  • Develop and sustain positive working relationships with internal and external customers.
  • Utilize outcomes data to improve ongoing care management services.

Requirements

  • Current RN state licensure required.
  • Additional specific state licensure(s) may be required depending on where clinical care is being provided.
  • 3 years of related, progressive clinical experience in the area of specialization.
  • Experience in a clinical setting.
  • Preferred: Experience in UM/CM/QA/Managed Care, WV RN license, Certification in utilization management or a related field.

Skills

  • Working knowledge of pertinent regulatory and compliance guidelines and medical policies.
  • Ability to multitask 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.


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