Pediatric RN Nurse Case Manager Sr.

Elevance Health•Washington, DC

1d•$91,724 - $137,586•Hybrid

About The Position

The Pediatric Nurse Case Manager Sr. is responsible for care management within the scope of licensure for members with complex and chronic care needs. This involves assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Duties may be performed telephonically or on-site, such as at hospitals for discharge planning. The role requires ensuring member access to appropriate services, conducting assessments to identify needs and develop care management plans, facilitating authorizations and referrals, coordinating resources, and monitoring the effectiveness of care plans. The position also involves interfacing with Medical Directors and Physician Advisors, negotiating reimbursement rates, assisting with provider and claims issues, and contributing to the development of utilization/care management policies and procedures. Additionally, the role may involve developing specialized knowledge in specific disease processes or traumatic injuries, functioning as a preceptor for new staff, and participating in department audit activities.

Requirements

Requires BA/BS in a health related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current, unrestricted RN license from the state which you reside is required.
Multi-state licensure is required if this individual is providing services in multiple states.

Nice To Haves

Experience in Pediatrics is very strongly preferred.
Certification as a Case Manager is preferred.

Responsibilities

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.
Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.
May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff.
Participates in department audit activities.