Pediatric RN Case Manager

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Pedi Case Manager

The Role The Clinical Care Manager is responsible for facilitating care for members and families of members who may have rising health risks or complex healthcare needs, to promote optimal health.

This position is self-directed and works independently and collaboratively to facilitate care based on the principles of care management. Facilitation is focused on assessing needs, identifying health care disparities, social determinants of health, and any barriers to care.

The Team The Clinical Care Manager is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care.

• Engage members in appropriate plans of care, coordinate care and services as appropriate, communicate effectively and provide members with education and resources as needed. Promote member compliance with treatment plan, encourage shared decision-making, and set appropriate goals to promote optimal member outcomes.
• Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow and appropriately document comprehensive care management plans.
• Review medication list and educate members with complex pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.
• Successfully connect, engage, and maintain member engagement to support seamless care transitions and optimized health outcomes.
• Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
• Monitor clinical quality concerns, make referrals appropriately, identify and elevate quality of care issues.
• Understand member insurance products and benefits, as well as regulatory and NCQA requirements.

• Ability to identify and document member-driven, specific, measurable activities that address actionable behaviors and goals.
• Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.
• Proficient with multiple IT systems.
• Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.

• 3-5 years relevant experience in a variety of appropriate pediatric clinical health care settings (Inpatient, outpatient, or differing levels of care).
• Utilization Management experience, preferred.
• Active licensure in Massachusetts is required, appropriate to position (RN/PT).
• Licensure in additional states a plus.
• Note:
  
  Any restrictions against a license must be disclosed and reviewed.

High school degree or equivalent required unless otherwise noted above.

Quincy

Time Type:
Full Time

Hourly Rate: $42.78 - $52.29

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer a comprehensive package of benefits, including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

We understand that confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant.

We encourage…