RN Nurse Case Manager I (Pediatrics) at Elevance Health in Hanover, Maryland

Posted in Other about 5 hours ago.





Job Description:

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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