Care Manager RN - Remote (Daylight Weekends & 3 Weekdays) at Highmark Health in Boise, Idaho, United States Job Description Company : Highmark Inc.
Job Description : JOB SUMMARY This job implements effective utilization management strategies including : review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach / case management, and identification and resolution of quality issues.
Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance / satisfaction and member satisfaction.
Responds to customer inquiries and offers interventions and / or alternatives. ESSENTIAL RESPONSIBILITIES + Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager's professional discipline.
- Function in accordance with applicable state, federal laws and regulatory compliance. + Implement all care management reviews according to accepted and established criteria, as well as other 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 and within the framework of applicable laws.
- Practice within the scope of ethical principles. + Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching / case management interventions.
- Employ collaborative interventions which focus, facilitate, and maximize the member's health care outcomes. Is familiar with the various care options and provider resources available to the member.
- Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
- Develop and sustain positive working relationships with internal and external customers. + Utilize outcomes data to improve ongoing care management services.
- Other duties as assigned or requested. EDUCATION Required + None Substitutions + None Preferred + Bachelor's Degree in Nursing EXPERIENCE Required + 3 - 5 years of related, progressive clinical experience in the area of specialization + Experience in a clinical setting Preferred + Experience in UM / CM / QA / Managed Care LICENSES AND CERTIFICATIONS To view full details and how to apply, please login or create a Job Seeker account
Care Manager Rn - Remote (daylight Weekends & 3 Weekdays)
Care Manager RN - Remote (Daylight Weekends & 3 Weekdays) at Highmark Health in Boise, Idaho, United States Job Description Company : Highmark Inc. ESSENTIAL RESPONSIBILITIES + Implement care management review processes that are consistent with established industry and corporate standards and are wi...
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