JOB SUMMARY

This job is responsible for providing comprehensive case management services to members with behavioral health needs, ensuring quality, cost-effective care delivery, and promoting optimal health outcomes. The Case Manager assesses member needs, develops and implements care plans, coordinates services, and monitors progress, while containing the cost of health care services. The incumbent will assist in containing the cost of health care services by detecting, resolving and preventing improper utilization of member benefits.

ESSENTIAL RESPONSIBILITIES

• Manage a caseload of members with moderate complexity behavioral health needs.
• Function as a primary contact for members with behavioral health needs with the depth of engagement ranging from coaching interventions to intensive case management interventions.
• Assess members' health status, needs, and available resources.
• Develop individualized care plans in collaboration with members, physicians, and other healthcare providers.
• Implement and coordinate care plans, ensuring access to appropriate services and resources.
• Develop and implement care plans with guidance from senior staff.
• Monitor member progress toward goals and adjust care plans as needed.
• Proactively incorporate lifestyle improvement and prevention opportunities into member interactions and coaching.
• Communicate with the members' treating provider(s) in more complex clinical situations requiring case management interventions.
• Evaluate the effectiveness of interventions and services.
• Act as an advocate and liaison to meet a member's individual health care needs by assessing, planning, implementing, coordinating, monitoring and evaluating options and services. This is accomplished by using communication and available resources to promote quality, cost-effective outcomes in accordance with available contract benefits.
• Work collaboratively and communicate clearly and professionally with physicians, providers, co-workers and other members of the health care team to carry out the established plan of care.
• Ensure all activities are documented and conducted in compliance with applicable business process requirements, company policies, regulatory requirements and accreditation standards.
• Identify areas for potential cost savings, quality improvement and workflow efficiencies.
• Other duties as assigned or requested.

EDUCATION

Required

• Master's degree if licensed Behavioral Health Professional OR Associate's degree with RN license

Preferred

• Bachelor's or Master's degree in Nursing if licensed as RN

EXPERIENCE

Required

• 3 years of experience in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance

Preferred

• Experience working with the healthcare needs of diverse populations
• Experience demonstrating understanding of importance of culture competency in addressing targeted populations

LICENSES AND CERTIFICATIONS

Required

Any of the following:

• Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• Licensed Social Worker (LSW)
• Licensed Clinical Social Worker (LCSW)
• Licensed Master Social Worker (LMSW)
• Licensed Professional Counselor (LPC)
• Licensed Mental Health Counselor (LMHC)
• Licensed Marriage and Family Therapist (LMFT)

Preferred

• Certified Case Manager (CCM)

SKILLS

• Strong assessment and care planning skills.
• Ability to work independently and as part of a team.
• Proficiency in using Microsoft suite of applications, case management software and electronic health records.
• Understanding of healthcare systems and case management principles.

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Physical work site required

Yes

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 job 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.

Pay Range Minimum:
$68,400.00

Pay Range Maximum:
$105,900.00

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.