Highmark Health Care Manager RN - (In-Patient) in Pittsburgh, Pennsylvania


General Overview:

Responsible for the implementation of effective utilization management strategies including: review of appropriateness of health care services, application of criteria to assure 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 Job Functions:

  1. Implements care management review processes that are consistent with established industry and corporate standards and are within the care manager’s professional discipline. Effectively functions in accordance with applicable state, federal laws and regulatory compliance.

2 Implements all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies. Promotes quality and efficiency in the delivery of care management services.

  1. Respects the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws. Practices within the scope of ethical principles.

  2. Identifies and refers members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions. Employs 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.

  3. Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships. Develops and sustains positive working relationships with internal and external customers.

  4. Utilizes outcomes data to improve ongoing care management services.

  5. Other duties as assigned or requested.

Minimum Qualifications:

  • RN (Registered Nurse) license

  • 3-5 years of related, progressive clinical experience in the area of specialization. Grandfathered experience requirements effective August 2016.

  • Experience in a clinical setting

Preferred Qualifications:

  • Bachelor’s degree in nursing

  • Certification in utilization management or a related field

  • Experience in Utilization Management

  • Experience in Acute In-Patient authorization

Knowledge, Skills & Abilities:

  • 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

Referral Award Payout Level: 1


Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity