Medical Case Manager - Utilization management (UM) Remote

Highmark Health

2d•Remote

About The Position

JOB SUMMARY This job assures that members with complex medical and/or psychosocial needs have access to high quality, cost-effective health care. Assists in the holistic assessment, planning, arranging, coordinating, monitoring, evaluation of outcomes and activities necessary to facilitate member access to healthcare services. Advocates for the most appropriate care plan using sound clinical judgment; accurate planning, and collaboration with internal and/or external customers and contacts. Follows established regulatory guidelines, policies, and procedures in relation to member interventions and documentation of activities related to the member’s care and progress across the continuum of care. Facilitates and/or participates in interdisciplinary and/or interagency meetings, when necessary, to facilitate coordination of services/resources for members.

Requirements

Minimum Bachelor’s degree in nursing or RN certification in lieu of bachelor's degree or Master’s degree in Social Work, Counseling, Education, or related field and 3 years' experience in Acute or Managed Care/ experience with Medicaid or Medicare populations.
OR Bachelor’s degree in Social Work with five years’ experience in Acute or Managed Care/ experience with Medicaid or Medicare populations
Licensed Social Worker (LSW)-Non-Specific - State (OR)
Licensed Professional Counselor (LPC) - Non-Specific State (OR)
Licensed Bachelors Social Worker (LBSW) (OR)
Licensed Clinical Social Worker (LCSW) - Non-Specific (OR)
Licensed Master Social Worker (LMSW) Non-Specific (OR)
Licensed Graduate Social Worker (LGSW) (OR)
Licensed Certified Social Worker (LCSW). Incumbents in the role prior to 1/1/25 who are not currently licensed must obtain licensure by 6/30/2026. (OR)
Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

Nice To Haves

Experience working with high-risk pregnant women OR experience working with chronic condition adult populations OR experience with pediatrics
3 years of experience in working in Acute Care/Managed Care/Medicaid and Medicare populations.
Bilingual English/Spanish language skills.
Case Management Certification

Responsibilities

Communicate effectively while performing customer telephonic interviewing and communication with external contacts.
Communicate effectively while interacting with Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.
Maintain knowledge of Medical Terminology and Medical Diagnostic Categories/Disease States
Educate members to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes.
Collaborate with Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care.
Collect member medical information from a variety of sources including providers and internal records and use appropriate clinical judgment, consultation with internal Physician Advisors and other internal cross-departmental consultation to determine unmet member needs.
Work primarily independently to identify, define, and resolve a myriad of problem types experienced by the member.
Develop an individualized plan of care designed to meet the specific needs of each member.
Anticipate the needs of members by continually assessing and monitoring the member’s progress toward goals, care plan status, and re-adjust goals when indicated.
Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services.
Be knowledgeable of and consider benefit design and cost benefit analysis when planning a course of intervention to develop a realistic plan of care.
Communicate and collaborate with other payers (when applicable) to create a collaborative approach to care management and benefit coordination.
Maintain a working knowledge of available community resources available to assist members.
Coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible.
Work within a Team Environment.
Attend and participate in required meetings, including staff meetings, internal Rounds, and other in-services to enhance professional knowledge and competency for overall management of members.
Participate in departmental and/or organizational work and quality initiative teams.
Case collaborates with peers, Case Management Specialists, Management Team, Physician Advisors and other interdepartmental contacts.
Participate in interagency and/or interdisciplinary team meetings when necessary to facilitate coordination of member care and resources.
Foster effective work relationships through conflict resolution and constructive feedback skills.
Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.
Educate health team colleagues of the role and responsibility of Case Management and the unique needs of the populations served to foster constructive and collaborative solutions to meet member needs.
Other duties as assigned or requested.