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.
  
  

• 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.
  
  

• 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.