Transplant Care Nurse - Remote

DescriptionJOB SUMMARYThis job implements effective complimentary utilization and case management strategies for an assigned member panel.Provides oversight over a specified panel of members that range in health status / severity and clinical needs; and 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 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.Will work with providers to insure quality and appropriate care is being delivered in a timely manner.ESSENTIAL RESPONSIBILITIESMaintain 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.Implement care management review processes that are consistent with established industry, corporate, state, and federal law standards and are within the care manager's professional discipline.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 all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.Other duties as assigned.EDUCATIONRequiredHigh School / GEDSubstitutionsNonePreferredBachelor's Degree in NursingEXPERIENCERequired7 years in any combination of clinical, case / utilization management and / or disease / condition management experience, or provider operations and / or health insurance experience1 year in a clinical settingPreferred5 years in UM / CM / QA / Managed Care1 year in advanced training and experience in cognitive behavioral therapy (CBT), motivational interviewing or dialectical behavior therapy (DBT)1 year working with the healthcare needs of diverse population and understanding of the importance of cultural competency in addressing targeted populationsLICENSES or CERTIFICATIONSRequiredRN license in PA or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment.PreferredCertification in utilization management or a related fieldCertification in Case ManagementSKILLSWritten and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassionBroad knowledge of disease processesWorking knowledge of pertinent regulatory and compliance guidelines and medical policiesAbility to multi task and perform in a fast paced and often intense environmentUnderstanding of healthcare costs and the broader healthcare service delivery systemAbility to analyze data, measure outcomes, and develop action plansBe enthusiastic, innovative, and flexibleBe a team player who possesses strong analytical and organizational skillsDemonstrated ability to prioritize work demands and meet deadlinesExcellent computer and software knowledge and skillsLanguage (Other than English) :NoneTravel Requirement :0% - 25%PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONSPosition TypeOffice-basedTeaches / trains others regularlyOccasionallyTravel regularly from the office to various work sites or from site-to-siteRarelyWorks primarily out-of-the office selling products / services (sales employees)NeverPhysical work site requiredYesLifting :up to 10 poundsConstantlyLifting :10 to 25 poundsOccasionallyLifting :25 to 50 poundsOccasionallyPay Range Minimum :$57,700.00Pay Range Maximum :$107,800.00Highmark 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.We endeavor to make this site accessible to any and all users.If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.For accommodation requests, please contact HR Services Online at. Experience: 5 years required