Highmark Health Case Manager in Pittsburgh, Pennsylvania

Description

I. GENERAL OVERVIEW:

This position is responsible for the provision of telephonic case management services to members in an area of clinical specialization and/or co-managing members with other case management staff. Case Managers provide services to members within their area of clinical specialty such as transplants, oncology, Baby BluePrints/high-risk pregnancy, neonatal care, pediatrics, cardiology, and neurotrauma. The Case Manager supports members in developing self-management skills and adopting positive behavior changes, identifies and addresses barriers to member’s adherence to standards of evidence-based medicine, helps members to coordinate care and navigate the healthcare system, identifies on-line, telephonic and community-based resources to assist members in achieving their personal health goals, and proactively incorporates lifestyle improvement and prevention opportunities into member interventions.

II. ESSENTIAL RESPONSIBILITIES:

  1. Functions as a primary clinician for members with complex health needs with the depth of engagement ranging from basic coaching to intensive case management. Across the continuum of services the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making.

  2. Conducts telephonic clinical assessments that address the health and wellness needs of Highmark members using a broad set of clinical and motivational interviewing skills with the goal of effecting members’ self-management and positive behavior changes.

  3. Develop case or condition-specific plans of care using the clinical information system to establish short and long-term goals. Establishes a plan for regular telephonic contact with each member to review progress and assess the potential for additional needs.

  4. Communicates with the member’s treating provider or providers in more complex clinical situations requiring case management intervention. Also serves as a subject matter expert to clinicians from other HMS teams to provide education, consultation, and training when indicated.

  5. Identifies on-line, telephonic and community-based resources that can assist the member to achieve and maintain their personal health goals and assists the member to access those services.

  6. Proactively incorporates lifestyle improvement and prevention opportunities into member interactions and coaching.

  7. Ensures that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.

  8. Other duties as assigned or requested, such as coordination of Blue Distinction Centers for Transplant Excellence for their services to ensure that members access these facilities whenever applicable. Senior Specialized Case Managers also work closely with Benefits Analysts to coordinate interpretation of benefit language and to ensure that all related services such as appeals/denials, provider inquiries, and claims processing are completed thoroughly and accurately.

III. QUALIFICATIONS:

Minimum

  • Ability to work flexible schedule

  • Current PA RN license and additional states may be required.

  • Clinical experience in the desired area of nursing specialization.

Preferred

  • Case Management Certification (CCM)

  • BSN, MSN, LSW, or LCSW

  • Certification in desired area of nursing specialization

  • Experience working with the healthcare needs of diverse populations.

  • Experience working in Maternity or Obstertrics

  • Understanding of the importance of cultural competency in addressing targeted populations.

  • Ability to communicate effectively in more than one language.

  • Understanding of the role of lifestyle in disease processes.

  • Call center experience desirable.

IV. SCOPE OF RESPONSIBILITY (People Management Responsibility)

Does this role supervise/manage other employees? No x Yes □

If yes, indicate the number of direct reports:

V. WORK ENVIRONMENT

Is Travel Required?

Yes, will meet members face to face

Physical Demands

None.

This job requires the ability to work independently and as a team member. Additionally, this job requires the willingness and ability to report to work on a regular and timely basis and may require irregular work hours, holidays and/or weekends.

REQNUMBER: J124684

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled