Company :Highmark Inc.
Job Description :
This job assures that Pediatric members with medical and psychosocial needs have access to high quality, cost-effective health care. This role supports members through motivational enhancement by developing goals, self-management skills and behaviors that impact well-being and lifestyle changes. The incumbent will also encourage engagement in low intensity interventions. This is accomplished by assisting in the initial screening, identifying gaps in care and barriers to adherence, goal setting, planning, arranging, coordinating, necessary to facilitate member access to healthcare services and community resources. Conducting accurate planning, and collaborating with internal and/or external customers and contacts. Following established regulatory guidelines, policies, and procedures in relation to member interventions and documentation of activities related to the member’s care and progress across the continuum of care. Facilitating and/or participating in interdisciplinary and/or interagency meetings, when necessary, to facilitate coordination of services/resources for members. The overall goal is to help members navigate the health care system and develop condition self-management skills through behavior change. This is a Pediatric focused position that will be working with our member population 17 and under and their families.
- Communicate effectively while performing customer telephonic motivational interviewing with external contacts. Educate members in order to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes including health behavior changes.
- Collaborate with Case Management Specialists, Management Team, Physician Advisors, Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care.
- Collect member medical information from a variety of sources including providers and internal records and use appropriate clinical judgment, consultation with internal Physician Advisors and other internal cross-departmental consultation to determine unmet member needs. Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services.
- Attend and participate in required meetings, interagency and/or interdisciplinary team meetings, including staff meetings, internal rounds, and other in-services in order to enhance professional knowledge and competency for overall management of members. Participate in departmental and/or organizational work and quality initiative teams. Attend internal and external continuing education forums annually to enhance overall clinical skills and maintain professional licensure, if applicable.
- Educate health team colleagues of the role and responsibility of Case Management and the unique needs of the populations served in order to foster constructive and collaborative solutions to meet member needs.
- Other duties as assigned or requested.
- Bachelor's Degree in Nursing, Health Education or related field
- 6 years of related and progressive experience in lieu of Bachelor's degree
- Master's Degree in Nursing, Health Education or related field
- 3 years in Acute or Managed Care OR Behavioral and Mental Health roles
- Pediatric experience and knowledge around Spectrum disorders, eating disorders, ADHD, gender dysphoria, family systems and therapeutic resources,.
LICENSES or CERTIFICATIONS
Board Certified Coach
- Ability to manage critical conversations
- Effective communication skills (listening, verbal and written)
- Comfort in leading one-on-on conversations while practicing clinical and motivational interviewing skills
- Capacity to work under pressure
- Ability to identify risk and gaps in care
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.
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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
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