Care manager Job at Highmark Health, Des Moines, IA

UXdXK2xSWVpIc0Z0bi8zSVFqc3h4b2dJYVE9PQ==
  • Highmark Health
  • Des Moines, IA

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 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

+ Current RN state licensure required. Additional specific state licensure(s) may be required depending on where clinical care is being provided.

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-Based

Teaches/trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Does Not Apply

Works primarily out-of-the office selling products/services (sales employees)

Does Not Apply

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely, 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._

Pay Range Minimum:

$50,200.00

Pay Range Maximum:

$91,200.00

_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._

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 any category protected by applicable federal, state, or local law.

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 the email below.

For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Req ID: J261031

Job Tags

For contractors, Local area, Flexible hours,

Similar Jobs

NTT DATA, Inc.

QA Tester Job at NTT DATA, Inc.

 ...apply now. We are currently seeking a QA Tester to join our team in Tiverton, Ontario (...  ...tests). General Skills Experience in planning, organizing and implementing...  ...experience in the use of Computer Aided Software Engineering (CASE) tools and data query... 

Cornerstone Custom Construction

General Carpentry Laborer Job at Cornerstone Custom Construction

 ...Job Title: Laborer Job Category: General Entry Level Department/Group: Carpentry Location: Ramsey, MN Travel Required: Travel Required Level/Salary Range: (Based on Experience) Position Type: Part/Full-Time HR Contact: Ulana Purcell Will Train Applicant... 

University of Southern California (USC)

Echo Technician - VHH Surgery Clinic - Full Time 8 Hour Days (Non-Exempt) (Non-Union) | University of Southern California (USC) Job at University of Southern California (USC)

 ...As an integral part of the Department, the Echo Tech is responsible for performing multiple diagnostic non-invasive Cardiology procedures. The Echo Tech is responsible for performing, supporting and participating in multiple diagnostic non-invasive Cardiology procedures... 

Great Clips Mill Creek Plaza

Hair Stylist - Part Time Job at Great Clips Mill Creek Plaza

 ...! Join a locally owned Great Clips salon, the worlds largest salon brand, and be one of the GREATS. Whether youre new to the industry or have years behind the chair great opportunities await. Hair Stylist/Barber Qualifications: Cosmetology and/or Barber License... 

Transporting Logistics

Trainee OTR CDL-A Driver Job at Transporting Logistics

Limited-time opportunity: OTR TraineeReefer Driver.After training stage, you will make $1300 weekly. Gain experience with us! JOB For driver who got their CDL-A recently Route: All 48 states - OTR Home time: Bi-Weekly Freight:Reefer Payment Starting...