Complex Case Manager RN

Highmark   •  

Home, PA

Industry: Accounting, Finance & Insurance


8 - 10 years

Posted 159 days ago

This job is no longer available.



This job has primary ownership and oversight over a specified panel of members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.


  • Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support.
  • For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment.
  • Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved.
  • Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.

  • Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization.

  • Other duties as assigned or requested.



  • High School Diploma/GED
  • 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience


  • Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT)
  • Experience working with the healthcare needs of diverse populations
  • Understanding of the importance of cultural competency in addressing targeted populations
  • Bachelor's Degree in Nursing



  • RN license in PA, WV, and DE is required. At least one of these state licensures must be active at time of hire. Others must be obtained within the first 6months of employment. Additional state licensure may be required.


  • Certification in Case Management


  • Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion
  • Broad knowledge of disease processes
  • Understanding of healthcare costs and the broader healthcare service delivery system
  • Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data
  • Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization
  • Ability to work in a high performing team environment that requires flexibility
  • Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills
  • Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy