RN Nurse Case Manager I (Pediatrics)
Elevance Health

Job Info

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LOCATION: This is a remote opportunity and you must be within 50 miles of our Hanover, Maryland office. Maryland residency is required.

HOURS: General business hours, Monday through Friday: 8:30 am - 5:30 pm

TRAVEL: Occasional visits to the office may be required for team meetings or training.

The Nurse Case Manager I (Pediatrics) is responsible for performing care management within the scope of licensure for youngest members with complex and chronic care. They are responsible for those members at highest risk for a rapid readmission, thus promptly engaging them to assess and address red flags, improve the quality of care, and allow for real-time oversight. Performs duties telephonically.

Primary duties may include, but are not limited to:

• Ensures member access to services appropriate to their health needs.
  
• Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
  
• Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
  
• Coordinates internal and external resources to meet identified needs.
  
• Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
  
• Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
  
• Negotiates rates of reimbursement, as applicable.
  
• Assists in problem solving with providers, claims or service issues.
  

Required Qualifications

• Requires BA/BS in a health related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
  
• Current, unrestricted RN license from the state of Maryland is required.
  

Preferred Qualifications

• Previous dedicated pediatric/high-risk pediatric nursing experience is must for this role!
  
• Previous experience as a case manager is strongly preferred.
  
• Previous Medicaid and/or Managed Care experience is very helpful.
  

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