Highmark Health Enhanced Complex Care Manager RN in Harrisburg, Pennsylvania

Description

JOB SUMMARY

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.

ESSENTIAL RESPONSIBILITIES

  • 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.

EDUCATION

Required

  • None

Substitutions

  • None

Preferred

  • Bachelor's Degree in Nursing

EXPERIENCE

Required

  • 5 - 7 years of Case Management Experience, Clinical Practice Experience, or Disease/Condition Management Experience

Preferred

  • None

LICENSES OR CERTIFICATIONS

Required

  • Registered Nurse

Preferred

  • ACM Certification (Accredited Case Manager)

  • Certified Chronic Care Manager (CCM)

SKILLS

Required

  • Microsoft Excel

  • Communication Skills

  • Collaboration

  • Self Starter

  • Health Education

  • Healthcare Industry

  • Friendly Personality

  • Flexibility

Preferred

  • Data Analysis

  • Statistical Analysis

Language (other than English)

0% - 25%

Travel Requirement

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Frequently

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Rarely

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Rarely

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.

REQNUMBER: J121336

Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity