Company :

Job Description : 

JOB SUMMARY

New Castle County territory - Registered Nurse

This community-based Case Manager position is responsible for delivering comprehensive case management services to DSHP Plus LTSS and DSNP members. The role requires frequent travel within an assigned territory for home or site visits to assess member needs, develop and implement care plans, evaluate benefits, coordinate services, and monitor progress. A key aspect of the position is to ensure quality and cost-effective care by preventing improper utilization of member benefits.

ESSENTIAL RESPONSIBILITIES

• Comprehensive Member Assessment: Conduct thorough assessments of members' health status, needs, and resources through in-person visits and ongoing phone support, managing a caseload with moderate complexity.
• Individualized Care Plan Management: Develop, implement, and monitor individualized care plans that address physical, behavioral, custodial, social, and psychosocial needs with minimal guidance.
• Holistic Service Coordination: Coordinate access to appropriate services, community resources, and specialists, ensuring efficient and cost-effective delivery across care settings.
• Member Advocacy: Serve as a primary advocate, guiding members and caregivers through healthcare decisions, and helping them overcome barriers to achieve care plan goals.
• Care Transition & Continuity: Ensure seamless and appropriate care transitions between hospitals, community settings, and facilities.
• Outcome Evaluation: Continuously monitor member progress, evaluate the effectiveness of services, and proactively adjust care plans to optimize outcomes.
• Cost & Quality Improvement: Identify opportunities for cost savings, quality improvement, and workflow efficiencies in care delivery.
• Regulatory Adherence: Ensure all documentation and activities strictly comply with business processes, company policies, regulatory requirements, and accreditation standards.
• Benefit Maximization: Coordinate member benefits across all payor sources and actively work to prevent improper utilization of benefits.
• Perform other duties as assigned/requested.

QUALIFICATIONS

Required

• Bachelor's degree in Social Work or in health, human, or education services and 3 years of experience in long-term care, home health, hospice, public health, or assisted living OR
• Master’s degree in Social Work or in health, human, or education services and 1 year of experience in long-term care, home health, hospice, public health, or assisted living OR
• Current State RN or LPN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) and 2 years of experience in long-term care, home health, hospice, public health, or assisted living.

Substitutions

• None

Preferred

• One year in home clinical or case management experience
• Certified Case Manager (CCM)
• Licensed Bachelors Social Worker (LBSW)
• Licensed Masters Social Worker (LMSW)
• Licensed Clinical Social Worker (LCSW)
• Experience working with HIV/AIDS population
• Experience working with behavioral health population
• Experience working with developmental disabilities population
• Medicare and Medicaid experience
• Managed care experience

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.
• Time management abilities
• Understanding of healthcare systems and case management principles

Language (Other than English):

None

Travel Requirement:

25% - 50%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Works From Home

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

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.

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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 any category protected by applicable federal, state, or local law.

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