Medical Case Manager
New
H
Highmark Inc.Healthcare case management
Source API remote eligibility restrictions: United StatesFull-TimeManager
Salary72,700 - 116,600 USD per year
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Job Details
- Languages
- Bilingual English/Spanish language skills preferred
- Experience
- 3 years of experience in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience with RN licensure or a Master’s degree OR; 5 years’ experience with a Bachelor’s in Social Work
- Required Skills
- Microsoft OfficeEHR
Requirements
- Have 3 years of qualifying clinical, case/utilization management, disease condition management, provider operations, or health insurance experience with RN licensure or a Master’s degree, or 5 years’ experience with a Bachelor’s in Social Work.
- Meet the required education or licensure pathway: a bachelor’s degree in nursing, RN licensure, a master’s degree in social work, counseling, or a related field, or a bachelor’s degree in social work.
- Hold an applicable required credential: a listed state social work or counseling license, current state RN licensure, or current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
- Demonstrate strong assessment and care planning skills.
- Be able to work independently and as part of a team.
- Use Microsoft Office, case management software, and electronic health records.
- Understand healthcare systems and case management principles.
- Medicaid managed care and/or Medicare experience is preferred.
- Experience working with diverse populations and understanding cultural competency is preferred.
- Certified Case Manager (CCM) certification is preferred.
- Bilingual English/Spanish language skills are preferred.
Responsibilities
- Manage a caseload of members with moderate complexity health needs.
- Assess members’ health status, needs, and available resources.
- Develop individualized care plans with members, physicians, and other healthcare providers.
- Implement and coordinate care plans to ensure access to appropriate services and resources.
- Coordinate referrals to specialists and community resources.
- Monitor member progress toward goals and adjust care plans as needed.
- Evaluate the effectiveness of interventions and services.
- Advocate and liaise to meet members’ individual healthcare needs using available resources and contract benefits.
- Document activities and comply with business processes, company policies, regulatory requirements, and accreditation standards.
- Identify potential cost savings, quality improvement, and workflow efficiencies.
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