Complex Case Manager RN - (Remote) at Highmark Health

About the position The position at Highmark Inc. involves primary ownership and oversight of a specified panel of members with varying health statuses and clinical needs. The incumbent is responsible for assessing the health management needs of the assigned member panel and utilizing data and analytics alongside professional clinical judgment to identify the appropriate clinical interventions for each member. This role is supported by a multi-disciplinary team, allowing the incumbent to refer members to suitable resources as needed. In addition to identifying clinical interventions and referrals, the incumbent will manage an active caseload of members enrolled in case management. This includes conducting outreach to these members, developing personalized care plans, encouraging behavior changes, addressing barriers to care, coordinating care, and identifying resources to assist members in achieving their health goals. The incumbent is also tasked with monitoring, improving, and maintaining quality outcomes—clinical, financial, and functional—for the specified panel of members. The essential responsibilities include maintaining oversight of the member panel through ongoing assessments, creating care plans that address identified needs, ensuring targeted patient goal achievement, and documenting all activities in compliance with business processes and regulatory requirements. The incumbent must stay informed about applicable CMS, state, local, and regulatory agency requirements and standards of practice for case management. Other duties may be assigned as necessary. Responsibilities • Maintain oversight over specified panel of members by performing ongoing assessment of members' health management needs. , • Identify the right clinical interventions to address member needs and/or triage members to appropriate resources for additional support. , • Create care plans for assigned caseload to address members' identified needs, remove barriers to care, and identify resources. , • Conduct outreach to members enrolled in case management, including developing care plans and encouraging behavior changes. , • Monitor and ensure targeted percentage of patient goal achievement and other patient outcomes are achieved. , • Document all activities in compliance with applicable business process requirements, regulatory requirements, and accreditation standards. , • Maintain current knowledge of applicable CMS, state, local, and regulatory agency requirements and standards of practice for case management. Requirements • High School Diploma/GED required; Bachelor's Degree in Nursing preferred. , • 7 years of any combination of clinical, case management, and/or disease/condition management experience, provider operations, and/or health insurance experience required. , • Advanced training and experience in motivational interviewing preferred. , • Experience working with the healthcare needs of diverse populations preferred. , • Understanding of the importance of cultural competency in addressing targeted populations preferred. , • Prior experience working with Federal Employee Program members preferred. , • Pediatric Nursing Experience preferred. , • RN license in PA, WV, DE, or NY required; other RN licenses must be obtained within the first 6 months of employment. , • Certification in Case Management preferred. Nice-to-haves • Experience working with diverse populations in healthcare settings. , • Advanced training in motivational interviewing techniques. , • Pediatric nursing experience.

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