Specialist Case Manager RN

Company :

Job Description :

JOB SUMMARY

This 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

• Provide case management services to members with highly complex or specialized needs (e.g., transplant, oncology, pediatrics, cardiology, and complex comorbidities).

• 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.

• Develop and implement innovative strategies to improve outcomes and reduce costs for specialized populations.

• 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.

• Serve as a subject matter expert and provide training to other case managers.

• Other duties as assigned or requested.

EXPERIENCE

Required

• 7 years of experience 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

• In-depth knowledge of the specialized area, including best practices and emerging treatments.

• Expertise in navigating complex healthcare systems and resources.

• Strong analytical and problem-solving skills.

• Strong proficiency in using Microsoft suite of applications, case management software and electronic health records.

• Excellent communication and presentation skills

• Skill in using generative AI

• Ability to interpret data and make data-based recommendations

EDUCATION

Required

• Bachelor’s degree in Nursing or relevant experience and/or education as determined by the company in lieu of bachelor's degree.

Preferred

• None

LICENSES or CERTIFICATIONS

Required

• 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):

None

Travel Required:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based or Remote Position

Physical work site required

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 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:

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.

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Originally posted on Himalayas