Complex Case Manager RN – Pediatrics (Remote) at Highmark Health in Boise, Idaho, United States Job Description Company : Highmark Inc. Job Description : JOB SUMMARY This job has primary ownership and oversight over a specified panel of members. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent is responsible for assisting members through their hospitalizations and discharge to address all healthcare needs. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial, and functional) for the specified panel of members. ESSENTIAL RESPONSIBILITIES + 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. + For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment. + Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved. + Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards. + Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization. + O To view full details and how to apply, please login or create a Job Seeker account
