JOB SUMMARYThis job is responsible for providing comprehensive case management services to members, 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 complex health needs, requiring advanced clinical knowledge.
- Conduct comprehensive assessments and develop complex care plans.
- 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.
- Monitor member progress toward goals and adjust care plans as needed.
- 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.
- Provide guidance and mentorship to lower-level Case Managers.
- Serve as a resource for clinical expertise and problem-solving.
- Other duties as assigned or requested.
EXPERIENCERequired- 5 years in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience.
Preferred- Specialty specific clinical experience (e.g., Oncology, Transplant, Maternity, NICU, Pediatric)
- Experience working with the healthcare needs of diverse populations
- Experience demonstrating understanding of importance of culture competency in addressing targeted populations
- Advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing, or dialectical behavior therapy (DBT)
SKILLS- Expertise in clinical assessment and care planning.
- Strong leadership and mentoring skills.
- Excellent negotiation and advocacy skills.
- Proficiency in using Microsoft suite of applications, case management software and electronic health records.
- Strong understanding of healthcare systems and case management principles.
EDUCATIONRequiredPreferredLICENSES or CERTIFICATIONSRequired- Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
- Certified Case Manager (CCM) certification must be obtained within 36 months of hire. Incumbents in the role as of August 2026 are exempt from this requirement.
Preferred- Certification in clinical area of expertise (e.g., OCN, CPN, CPON, CNN, CCTC, CPHQ).
Language (Other than English):Travel Required:PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition Type- Office-Based or Remote Position
Physical work site requiredDisclaimer: 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:$79,300.00
Pay Range Maximum:$127,100.00
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.
