Company :Highmark Wholecare
Job Description :
This job is responsible for the provision of telephonic case management services to members in an area of clinical specialization and/or co-managing members with other case management staff. The incumbent provides services to members within their area of clinical specialty such as transplants, oncology, Baby BluePrints/high-risk pregnancy, neonatal care, pediatrics, cardiology, and neurotrauma. Supports members in developing self-management skills and adopting positive behavior changes, identifies and addresses barriers to member’s adherence to standards of evidence-based medicine, helps members to coordinate care and navigate the healthcare system, identifies on-line, telephonic and community-based resources to assist members in achieving their personal health goals, and proactively incorporates lifestyle improvement and prevention opportunities into member interventions.
- Function as a primary clinician for members with complex health needs with the depth of engagement ranging from basic coaching to intensive case management. Across the continuum of services the goal is always to help develop and support the member’s ability to self-manage and navigate the health care system and to provide members with resources and tools to assist in health-related decision making.
- Conduct telephonic clinical assessments that address the health and wellness needs of the Organization's members using a broad set of clinical and motivational interviewing skills with the goal of effecting members’ self-management and positive behavior changes.
- Develop case or condition-specific plans of care using the clinical information system to establish short and long-term goals.
- Establish a plan for regular telephonic contact with each member to review progress and assess the potential for additional needs.
- Communicate with the member’s treating provider or providers in more complex clinical situations requiring case management intervention.
- Serve as a subject matter expert to clinicians from other HMS teams to provide education, consultation, and training when indicated.
- Identify on-line, telephonic and community-based resources that can assist the member to achieve and maintain their personal health goals and assists the member to access those services.
- Proactively incorporate lifestyle improvement and prevention opportunities into member interactions and coaching.
- Ensure that all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.
- Coordinate Blue Distinction Centers for Transplant Excellence for their services to ensure that members access these facilities whenever applicable.
- Work closely with Benefits Analysts to coordinate interpretation of benefit language and to ensure that all related services such as appeals/denials, provider inquiries, and claims processing are completed thoroughly and accurately.
- Other duties as assigned or requested.
- Ability to work flexible schedule
- Current PA RN license and additional states may be required
- Clinical experience in the desired area of nursing specialization
- Case Management Certification (CCM)
- BSN or MSN
- Certification in desired area of nursing specialization
- Experience working with the healthcare needs of diverse populations
- Understanding of the importance of cultural competency in addressing targeted populations
- Ability to communicate effectively in more than one language.
- Understanding of the role of lifestyle in disease processes
- Call center experience desirable
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
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
Pay Range Minimum:$57,700.00
Pay Range Maximum:$106,700.00
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 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.
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