Clinical Case Management Registered Nurse

2 weeks ago

East Montpelier, Vermont, United States Highmark Health Full time

Company :

Highmark Inc.

Position Overview :

ROLE SUMMARY

The selected candidate will hold primary responsibility for overseeing a designated group of members, each with varying health conditions and clinical requirements. This role involves evaluating the health management needs of the assigned member group and leveraging data and analytics alongside professional clinical expertise to determine the most suitable clinical interventions for each individual. The incumbent will collaborate with a multidisciplinary team and exercise clinical judgment to direct members to appropriate resources. Additionally, the role includes managing an active caseload of members enrolled in case management.

KEY RESPONSIBILITIES

  • Continuously assess the health management needs of the designated member group, ensuring the identification of appropriate clinical interventions and referrals to additional resources as necessary.
  • Develop comprehensive care plans tailored to the identified needs of each member, addressing barriers to care and incorporating both short-term and long-term goals along with a schedule for regular follow-ups.
  • Achieve targeted outcomes related to patient goals and other relevant metrics.
  • Document all activities meticulously, ensuring compliance with business processes, regulatory standards, and accreditation requirements.
  • Stay informed of and adhere to applicable regulations and standards of practice for case management as established by relevant authorities.
  • Perform additional duties as assigned.

EDUCATIONAL REQUIREMENTS

Mandatory

  • High School Diploma or GED

Preferred

  • Bachelor's Degree in Nursing

EXPERIENCE REQUIREMENTS

Mandatory

  • A minimum of 7 years in clinical practice, case management, or related fields, including experience in provider operations or health insurance.

Preferred

  • Advanced training in motivational interviewing techniques.
  • Experience addressing the healthcare needs of diverse populations.
  • Understanding of cultural competency in healthcare.
  • Prior experience with Federal Employee Program members.
  • Pediatric nursing experience.

CERTIFICATIONS AND LICENSES

Mandatory

  • Active RN license in PA, WV, DE, or NY. Additional licenses must be obtained within the first six months of employment.

Preferred

  • Certification in Case Management.

SKILLS AND COMPETENCIES

  • Strong written and verbal communication skills, with the ability to negotiate and influence positively.
  • Comprehensive knowledge of disease processes.
  • Understanding of healthcare costs and the overall healthcare delivery system.
  • Proficiency in MS Excel and strong analytical skills for interpreting clinical and financial data.
  • Excellent interpersonal skills and the ability to collaborate with colleagues across various levels of the organization.
  • Capacity to thrive in a high-performance team environment with flexibility.
  • Ability to manage multiple priorities effectively in a fast-paced setting.
  • Self-motivated with the ability to work independently with moderate supervision.

LANGUAGE REQUIREMENTS

No additional language requirements.

TRAVEL REQUIREMENTS

Minimal travel expected (0% - 25%).

WORKING CONDITIONS

This position is primarily office-based, with occasional travel required. Physical demands include lifting up to 10 pounds rarely.

Disclaimer: This job description is intended to provide a general overview of the position and is not exhaustive of all duties and responsibilities.

Compliance Requirement: This role adheres to ethical and legal standards as outlined in company policies.

Pay Range:

Minimum: $57,700.00 | Maximum: $106,700.00

Highmark Health is an equal opportunity employer, committed to a diverse workforce.

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