Job Description
Company :
Highmark Inc.
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 ensure 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 manager’s 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
High School/GED
Substitutions
None
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
RN license in PA or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment.
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 HIPAA and company privacy policies and procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Procedures and Information Security Policy. It is every employee’s responsibility to comply with the company’s Code of Business Conduct and applicable laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum: $57,700.00
Pay Range Maximum: $107,800.00
Base pay is determined by a variety of factors including a candidate’s 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 protected veteran or disability status and prohibit discrimination based on any category protected by law.
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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
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