Chronic Care Manager (Remote - Compact States)

This job implements effective utilization management strategies, including reviewing the appropriateness of health care services, applying criteria to ensure appropriate resource utilization, identifying opportunities for referral to Health Coaching or case management, and identifying and resolving quality issues. The role monitors and analyzes health care service delivery, educates providers and members proactively, and analyzes qualitative and quantitative data to develop strategies for improving provider and member satisfaction. The incumbent also responds to customer inquiries and offers interventions or alternatives.ESSENTIAL RESPONSIBILITIESImplement care management review processes consistent with industry and corporate standards within the care manager’s professional discipline.Function in accordance with applicable state, federal laws and regulatory compliance.Execute all care management reviews according to accepted criteria, 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 within the framework of applicable laws.Practice within the scope of ethical principles.Identify and refer members whose health outcomes may be enhanced by Health Coaching or case management interventions.Employ collaborative interventions that focus on, facilitate, and maximize members’ health care outcomes; be familiar with the available care options and provider resources.Educate professional and facility providers and vendors to streamline and improve processes, while developing network rapport and relationships.Develop and sustain positive working relationships with internal and external customers.Utilize outcome data to improve ongoing care management services.Perform other duties as assigned or requested.EDUCATIONRequired: NoneSubstitutions: NonePreferred: Bachelor’s Degree in NursingEXPERIENCERequired: 3 years of related, progressive clinical experience in the area of specialization; experience in a clinical setting.Preferred: Experience in Utilization Management, Care Management, QA, or Managed Care.LICENSES AND CERTIFICATIONSRequired: Current State of PA RN licensure OR current multi‑state licensure through the enhanced Nurse Licensure Compact (eNLC). Additional specific state licensure(s) may be required depending on where care is provided.Preferred: Certification in Utilization Management or a related field.SKILLSWorking knowledge of relevant regulatory and compliance guidelines and medical policies.Ability to multitask and perform in a fast‑paced, often intense environment.Excellent written and verbal communication skills.Ability to analyze data, measure outcomes, and develop action plans.Enthusiastic, innovative, and flexible.Team player with strong analytical and organizational skills.Demonstrated ability to prioritize work demands and meet deadlines.Excellent computer and software knowledge and skills.TRAVEL REQUIREMENT 0% – 25%PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition Type: Office‑BasedTeaches/trains others regularly – OccasionallyTravel regularly from office to various work sites or site‑to‑site – Does Not ApplyWorks primarily out‑of‑the‑office selling products/services (sales employees) – Does Not ApplyPhysical work site required – YesLifting: up to 10 pounds – ConstantlyLifting: 10 to 25 pounds – OccasionallyLifting: 25 to 50 pounds – Rarely, OccasionallyPAY RANGE Minimum: $50,200.00Maximum: $91,200.00Highmark 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 any category protected by applicable federal, state, or local law.We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.For accommodation requests, please contact HR Services Online at [emailprotected]#J-18808-Ljbffr