Highmark Health Care Manager, RN in Barre, Pennsylvania

Company :

Job Description :

JOB SUMMARY

This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

ESSENTIAL RESPONSIBILITIES

  • Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline.

  • 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 which focus, facilitate, and maximize the member’s health care outcomes. Is familiar with the various care options and provider resources available to the member.

  • Educate professional and facility providers and vendors for the purpose of streamlining and improving 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.

  • Other duties as assigned or requested.

QUALIFICATIONS

Required

  • RN (Registered Nurse) license

  • 3 - 5 years of related, progressive clinical experience in the area of specialization. Grandfathered experience requirements effective August 2016.

  • Experience in a clinical setting

Preferred

  • Bachelor’s degree in nursing

  • Certification in utilization management or a related field

  • Experience in UM/CM/QA/Managed Care

Skills

  • 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

  • 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


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

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Highmark Health and its subsidiaries and affiliates comprise a national health and wellness organization that employs more than 40,000 people and serves nearly 50 million Americans in all 50 states and the District of Columbia. The organization includes businesses in health insurance, health care delivery, managed vision care, retail eyewear and eye care services, eyewear manufacturing, dental solutions, health risk solutions, and innovative, technology-based solutions. Highmark Health is the parent of Highmark Inc., Allegheny Health Network, HM Health Solutions, and HM Home and Community Services LLC.