Highmark Health

Clinical Transformation Partner RN (Remote)

Posted on

March 3, 2026

Job Type

Full-Time

Role Type

Clinical Operations

License

RN

State License

Compact / Multi-State

Apply to This Job

Help & Resources

Company Description

Job Description

This job works directly with network providers to support key clinical transformation programs with a focus on utilization of appropriate care. The team member works with internal and external stakeholders to ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. The team member will also work with providers to identify specific areas of improvement within the same domain and help providers develop meaningful action plans to improve performance. The team member is responsible for building relationships, engaging clinicians, educating on Utilization Management policies and processes, developing workflows and resources, and improving provider performance.

Requirements

Required: 5 years experience in any of the following healthcare areas:the provider environment (hospital, facility, PCP, specialist, supporting area(s)), or healthcare insurance industry, or healthcare administration in a provider office, hospital and/or health systems, or healthcare consulting in provider setting. 3 years of experience in utilization management/care management/QA/managed care Preferred: 3 years of experience in data analysis, interpretation, and outcomes strategic plan development. 1 year of lean, six sigma, TQI, TQC or other quality and/or project management certification SKILLS: Ability to analyze data, measure outcomes, and develop action plans Working knowledge of pertinent regulatory and compliance guidelines and medical policies Ability to multitask and perform in a fast-paced and often intense environment that requires flexibility Excellent written and verbal presentation skills, excellent interpersonal and negotiation skills, and ability to positively influence others.Engages with external stakeholders with a professional demeanor and customer-centered mindset. Be a team player who possesses strong analytical and organizational skills. EDUCATION Required: Bachelor’s degree in nursing OR licensed RN with associate's degree or RN diploma. Preferred: None LICENSES or CERTIFICATIONS Required: Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Preferred: PA Driver's license Certification in nursing area of expertise

Need help crafting an effective cover letter and resume for this role?

Get access to our expert resources: our proven framework offers successful strategies, helps you find the best-fit positions, craft standout cover letters, optimize your resume, and much more.

Get Started

Responsibilities

Review provider performance according to accepted and established criteria, as well as other approved guidelines and medical policies. Analyze qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Educate providers and other relevant external stakeholders on medical policy clinical criteria used to authorize care on a proactive basis. Develop and sustain positive working relationships with internal and external customers. Respond to customer inquiries and offers interventions and/or alternatives. Other duties as assigned or requested.

Apply to This Job

Help & Resources

Our Resources Designed for Success

Nurses who follow our proven framework increase their chances of landing a remote telehealth role by 5x!

Telehealth

Starter Pack

Telehealth

Pro Toolkit

Telehealth

Mastery Suite

Price

$34 one-time payment — no subscription $79 one-time payment — no subscription $149 one-time payment — no subscription

Resume Template Package

Checkmark Checkmark Checkmark
Matching Cover Letter Checkmark Checkmark Checkmark
Matching Reference Page Checkmark Checkmark Checkmark
Resume Tips and Tricks Checkmark Checkmark Checkmark
Resume Optimization Guide Checkmark Checkmark
7 Nurse Resume Examples Checkmark Checkmark
20+ Professional Summary Examples Checkmark Checkmark
How to Structure Unique Career Experiences Checkmark Checkmark

āœ…Career Accelerator Success Guide

Checkmark
šŸ”“Lifetime Premium Job Board Access

Checkmark
šŸ“ˆJob Application Tracker

Checkmark
⭐1:1 Expert Support & Mentorship

Checkmark

Basic

Telehealth

Starter Pack

$34

  • Checkmark

    Resume Template Package

    ATS optimized design for nurses

  • Checkmark

    Matching Cover Letter

  • Checkmark

    Matching Reference Page

  • Checkmark

    Resume Tips and Tricks

ADVANCED

Telehealth

Pro Toolkit

$79

  • Checkmark

    Everything from Starter Pack

  • Checkmark

    Resume Optimization Guide

  • Checkmark

    7 Nurse Resume Examples

  • Checkmark

    20+ Professional Summary Examples

  • Checkmark

    How to Structure Unique Career Experiences

BEST VALUE

Telehealth

Mastery Suite

$149

  • Checkmark

    Everything from Starter Pack

  • Checkmark

    Everything from Pro Toolkit

  • Checkmark

    Career Accelerator Success Guide

    Proven method for landing your dream role

  • Checkmark

    Lifetime Premium Job Board Access

  • Checkmark

    Application Tracker

  • Checkmark

    1:1 Expert Support