Manager of Care Managment - Highmark - Pittsburgh, PA

E-mail Mike.Foster@rightthinginc.com for more details!!!

Summary of Job Responsibilities:

• The Manager of Care Management is an expert in the areas of utilization management, continuum of care planning, benefit interpretation, disease management, insurance industry regulations as well as personnel management.
• Accountable for the oversight; development and maintenance of the department's care management processes. This includes utilization management, strategic planning, care cost initiatives, system development and quality outcomes.
• Responsible for compliance to NCQA, URAC, CMS, DOH, and DOL regulations.
• Responsible for appropriate application of Medical Policy and criteria.
• A representative of Healthcare Management Services across the corporation.
• Coordinates all department activities; staff education, policy and procedure development and revision, care and case management audits, oversees overall operations such as call volume, referrals to case management, Blues on Call and physician advisor area. Expected to be a role model to staff and able to assist in the day to day activities as needed.

Required Qualifications:

• High School Diploma
• 3-5 years experience in Clinical Nursing
• 7-10 years experience in a managed care environment

 Other requirements (licenses, certifications, specialized training, physical abilities needed to perform the job):

• Registered Nurse License

Preferred Qualifications:

• Additional relevant education level and/or years of experience:
  • Bachelor of Science in Nursing

Additional relevant knowledge and/or skills and/or work experience:

• 3-5 years in staff and project management
• Demonstrated Project Management skills.
• Excellent written and verbal communication skills.
• Ability to interact with all levels of the organization.
• Ability to interact with external customers and providers.
• Ability to analyze data, measure outcomes and develop action plans.
• Highly effective interpersonal skills.
• Recognized as a clinical nursing expert.
• Ability to intervene in crisis situations and multi-task.
• Excellent computer and software knowledge and skills.

 Additional relevant licenses, certifications, training, etc.:

• Certification in Care Management