Highmark Health Enhanced Community Care Manager, RN in Carnegie, Pennsylvania
This job works directly with providers in a variety of health care settings to appropriately identify members with chronic conditions and/or gaps in care that can be positively impacted in relation to quality and care costs. The incumbent could work in a physician’s office, visit physician practices on a routine basis, work within a hospital setting and/or visit the member’s home. This job directly helps members with the highest risk scores to coordinate care and navigate the healthcare system by recommending and/or implementing interventions related to the improvement of medical care and costs.
Conduct member-facing clinical assessments that address the health and wellness needs of the members with the highest risk scores using a broad set of clinical and motivational interviewing skills with the goal of impacting members’ self-management skills and positive behavior changes which will ultimately positively impact member satisfaction and care costs.
Serve as a subject matter expert to both internal and external sources (e.g. members, providers, regulatory agencies, UM and policy) to provide education, consultation, and training.
Serve as a resource to guide, mentor, and counsel others in regard to understanding the drivers of health care costs to improve member outcomes related to Plan benefits and resources.
Collaborate, coordinate, and communicate with the member’s treating provider(s) in more complex clinical situations requiring clinical and psychosocial intervention.
Develop and implement case-or condition-specific plans of care and/or intervention plans, as needed, that can become a part of the member’s medical record to establish short and long-term goals.
Establish a plan for regular contact (face-to-face as often as possible) with each member and/or provider to monitor progress toward goals, provide additional education and evaluate the need for modification or change in the plan of care.
Proactively incorporate lifestyle improvement opportunities and preventive care into member interactions and coaching
Collaborate with the appropriate individuals to offer solutions to refine and improve existing practices or participates in developing performance improvement processes that will enhance member outcomes and operational performance/excellence as well support all strategic initiatives including Health Care Reform and STARS initiatives.
Work with providers related to performance measures and activities to educate and influence the behavior of members and providers.
Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
Other duties as assigned.
- Bachelor's Degree in Nursing
- 5 - 7 years of Case Management Experience, Clinical Practice Experience, or Disease/Condition Management Experience
LICENSES OR CERTIFICATIONS
- Registered Nurse
ACM Certification (Accredited Case Manager)
Certified Chronic Care Manager (CCM)
Language (other than English)
0% - 25%
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity