Medical Case Manager

Highmark Health

Medical Case Manager ensuring members access to high quality healthcare services. Coordinating care and advocating for appropriate care plans in a remote role.

Posted 7/1/2026full-timeRemote • Pennsylvania • 🇺🇸 United StatesMid-LevelSenior💰 $72,700 - $116,600 per yearWebsite

About the role

Key responsibilities & impact

Assures that members with complex medical and/or psychosocial needs have access to high quality, cost-effective health care.
Assists in the holistic assessment, planning, arranging, coordinating, monitoring, evaluation of outcomes and activities necessary to facilitate member access to healthcare services.
Advocates for the most appropriate care plan using sound clinical judgment; accurate planning, and collaboration with internal and/or external customers and contacts.
Follows established regulatory guidelines, policies, and procedures in relation to member interventions and documentation of activities related to the member’s care and progress across the continuum of care.
Facilitates and/or participates in interdisciplinary and/or interagency meetings, when necessary, to facilitate coordination of services/resources for members.
Communicate effectively while performing customer telephonic interviewing and communication with external contacts.
Educate members to enhance member understanding of illness/disease impact and to positively impact member care plan adherence, pharmacy regimen maintenance, and health outcomes.
Collaborate with Primary Care Physicians, Medical Specialists, Home Health and other ancillary healthcare providers with the goal being to coordinate member care.
Collect member medical information from a variety of sources including providers and internal records and use appropriate clinical judgment, consultation with internal Physician Advisors and other internal cross-departmental consultation to determine unmet member needs.
Work primarily independently to identify, define, and resolve a myriad of problem types experienced by the member.
Develop an individualized plan of care designed to meet the specific needs of each member.
Anticipate the needs of members by continually assessing and monitoring the member’s progress toward goals, care plan status, and re-adjust goals when indicated.
Maintain a working knowledge of available resources for addressing identified member needs and to facilitate proactive and efficient provision of services.
Coordinate with community organizations/agencies for the purpose of identifying additional resources for which the MCO is not responsible.

Requirements

What you’ll need

Minimum Bachelor’s degree in nursing or RN certification in lieu of bachelor's degree or Master’s degree in Social Work, Counseling, Education, or related field and 3 years' experience in Acute or Managed Care/ experience with Medicaid or Medicare populations.
Bachelor’s degree in Social Work with five years’ experience in Acute or Managed Care/ experience with Medicaid or Medicare populations
Preferred Experience working with high-risk pregnant women or experience working with chronic condition adult populations or experience with pediatrics 3 years of experience in working in Acute Care/Managed Care/Medicaid and Medicare populations.
Bilingual English/Spanish language skills.
Case Management Certification
Required Licensed Social Worker (LSW)-Non-Specific - State (OR) Licensed Professional Counselor (LPC) - Non-Specific State (OR) Licensed Bachelors Social Worker (LBSW) (OR) Licensed Clinical Social Worker (LCSW) - Non-Specific (OR) Licensed Master Social Worker (LMSW) Non-Specific (OR) Licensed Graduate Social Worker (LGSW) (OR) Licensed Certified Social Worker (LCSW) (OR) Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

Benefits

Comp & perks

Health insurance
Professional development opportunities

ATS Keywords

✓ Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

Holistic AssessmentCare PlanningClinical JudgmentInterdisciplinary CollaborationTelephonic InterviewingMonitoring and EvaluationResource CoordinationProblem ResolutionMember EducationDocumentation

Soft Skills

Effective CommunicationAdvocacyCollaborationEmpathyOrganizational Skills

Certifications

Case Management Certification