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
Manage a caseload of members with moderate complexity health needs.
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.
Develop and implement care plans with guidance from senior staff.
Coordinate referrals to specialists and community 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.
Identify areas for potential cost savings, quality improvement and workflow efficiencies.
Other duties as assigned or requested.
EDUCATION
Required
High School Diploma/GED
Substitutions
None
Preferred
Bachelor's Degree in Nursing
EXPERIENCE
Required
3 years in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience
Preferred
Utilization Management
Registered Nurse
Case Management
Experience working with the healthcare needs of diverse populations
Experience demonstrating understanding of the importance of cultural competency in addressing targeted populations
LICENSES AND CERTIFICATIONS
Required
Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) or WV or DE or NY is required. Other RN license(s), if applicable, must be obtained within the first 6 months of employment.
SKILLS
Strong assessment and care planning skills.
Ability to work independently and as part of a team.
Proficiency in using Microsoft suite of applications, case management software and electronic health records.
Understanding of healthcare systems and case management principles
LANGUAGE REQUIREMENT (Other than English)
None
TRAVEL REQUIREMENT
0% - 25%
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
Position Type
Office-Based
Physical Work Site Required
No
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:
$72,700.00Pay Range Maximum:
$116,600.00Base 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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For accommodation requests, please contact HR Services Online at [email protected]
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Skills Required
- High school diploma or GED
- Three years of experience in clinical, case or utilization management, disease condition management, provider operations, and/or health insurance
- Current Pennsylvania RN license, or current multistate license through the enhanced Nurse Licensure Compact, or licensure in WV, DE, or NY
- Any other applicable RN license must be obtained within the first six months of employment
- Bachelor's degree in Nursing
- Utilization management experience
- Registered Nurse experience
- Case management experience
- Experience working with healthcare needs of diverse populations
- Experience demonstrating cultural competency in addressing targeted populations
- Strong assessment and care planning skills
- Ability to work independently and as part of a team
- Understanding of healthcare systems and case management principles
Highmark Health Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Highmark Health and has not been reviewed or approved by Highmark Health.
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Healthcare Strength — Medical, prescription, dental, and vision coverage are emphasized alongside 100% coverage for preventive exams, with onsite pharmacy access and fitness center availability at major campuses.
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Retirement Support — An employer‑sponsored 401(k) with a company match is highlighted, with AHN materials illustrating a 100% match on the first 4% plus an additional 1% employer contribution as an example within the enterprise.
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Wellbeing & Lifestyle Benefits — Wellness programs include stress‑management classes, health coaching, incentives for healthy activities, team‑member discounts, and volunteer incentives, with paid volunteer time also noted in the overall package.
Highmark Health Insights
What We Do
Highmark Health, a Pittsburgh, PA based enterprise that employs more than 40,000 people who serve millions of Americans across the country, is the second largest integrated health care delivery and financing network in the nation based on revenue. Highmark Health is the parent company of Highmark Inc., Allegheny Health Network, and HM Health Solutions. Highmark Inc. and its subsidiaries and affiliates provide health insurance to nearly 5 million members in Pennsylvania, West Virginia and Delaware as well as dental insurance, vision care and related health products through a national network of diversified businesses that include United Concordia Companies, HM Insurance Group, and Visionworks. Allegheny Health Network is the parent company of an integrated delivery network that includes eight hospitals, more than 2,800 affiliated physicians, ambulatory surgery centers, an employed physician organization, home and community-based health services, a research institute, a group purchasing organization, and health and wellness pavilions in western Pennsylvania. HM Health Solutions focuses on meeting the information technology platform and other business needs of the Highmark Health enterprise as well as unaffiliated health insurance plans by providing proven business processes, expert knowledge and integrated cloud-based platforms. A national blended health organization, Highmark Health and our leading businesses support millions of customers with products, services and solutions closely aligned to our mission of creating remarkable health experiences, freeing people to be their best. Headquartered in Pittsburgh, we're regionally focused in Pennsylvania, Delaware, West Virginia and New York, with customers in all 50 states and the District of Columbia. We passionately serve individual consumers and fellow businesses alike. Our companies cover a diversified spectrum of essential health-related needs, including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative technology solutions. We’re also proud to carry forth an important legacy of compassionate care and philanthropy that began more than 170 years ago. This tradition of giving back, reinvesting and ensuring that our communities remain strong and healthy is deeply embedded in our culture, informing our decisions every day.
