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Care Manager RN

Company: Highmark Health
Location: Salt Lake City
Posted on: August 6, 2022

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****Required**+ Active United States RN (Registered Nurse) license in any state is required upon hire. A WV license is required in addition to the home state license unless the home state license is part of the compact. The additional WV license must be obtained within the first 6 months of employment.**Preferred**+ Certification in utilization management or a related field**SKILLS**+ Working knowledge of pertinent regulatory and compliance guidelines and medical policies+ Ability to multi task and perform in a fast paced and often intense environment+ Excellent written and verbal communication skills+ Ability to analyze data, measure outcomes, and develop action plans+ Be enthusiastic, innovative, and flexible+ Be a team player who possesses strong analytical and organizational skills+ Demonstrated ability to prioritize work demands and meet deadlines+ Excellent computer and software knowledge and skills**Languages (Other than English)**None**Travel Requirement**0% - 25%**PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS****Position Type**Office-BasedTeaches/trains others regularlyOccasionallyTravel regularly from the office to various work sites or from site-to-siteDoes Not ApplyWorks primarily out-of-the office selling products/services (sales employees)Does Not ApplyPhysical work site requiredYesLifting: up to 10 poundsConstantlyLifting: 10 to 25 poundsOccasionallyLifting: 25 to 50 poundsRarely, Occasionally**_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.__As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.__Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._Highmark 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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.Highmark 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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.EEO is The LawEqual Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( _https://www.eeoc.gov/sites/default/files/migrated\_files/employers/poster\_screen\_reader\_optimized.pdf_ )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 number below.For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.orgCalifornia Consumer Privacy Act Employees, Contractors, and Applicants NoticeReq ID: J209019

Keywords: Highmark Health, Salt Lake City , Care Manager RN, Healthcare , Salt Lake City, Utah

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