Case Manager, Pediatrics (Registered Nurse) Case Manager, Pediatrics (Registered Nurse) role at Excellus BCBS
Overview
Provides case management program activities in accordance with departmental, corporate, NYS DOH, CMS, FEP, and NCQA accreditation standards as appropriate to the member’s case assignment. Uses a systematic approach to identify members meeting program criteria; educates, supports, coaches, coordinates care, and reviews treatment options in collaboration with providers and community-based resources.
Responsibilities Handles physical health member clinical management programs.
Maintains knowledge of current CMSA Standards, NCQA Standards, Case Management Program activities, and performs duties as directed by policy and leadership, including regulatory requirements for Medicare programs as applicable.
Performs responsibilities in accordance with departmental, corporate, state, federal, and accreditation standards, licensure, certification and scope of practice requirements for each health-related field.
Maintains confidentiality and conducts information management procedures per policy.
Implements the Case Management Process per department policies, including case identification, case opening, member assessment, education and support interventions, developing care plans, member-centric interventions, measuring outcomes, case closure, and case reviews.
Screens members within defined populations to determine appropriateness for case management services.
Initiates case management and opens appropriate cases timely; uses motivational interviewing to obtain essential information for meeting member health goals.
Collaborates with members’ physicians and other health care providers to assess needs, facilitate an interdisciplinary care plan, coordinate services, evaluate effectiveness, and modify the plan as necessary.
Assesses member/caregiver knowledge and initiates appropriate education interventions.
Collaborates with member/caregiver to set objectives, goals and actions to address needs and barriers.
Provides resources and assistance to manage health across the continuum of care; acts as a liaison between providers and community resources.
Participates in inter-disciplinary coordination to ensure delivery of quality health care services (e.g., Utilization Management, Quality, Behavioral Health, Pharmacy, Dietitian, Respiratory Therapist).
Maintains required continuing education per policy and certification standards where applicable.
Participates in and promotes other health plan programs and digital health tools.
Works collaboratively with all Case Managers to ensure continuity and coordination of care.
May work with internal and external stakeholders for value-based payment programs.
Maintains high standards of integrity and privacy in accordance with corporate policies.
May participate in orientation of new staff; regular attendance is expected.
Performs other functions as assigned by management.
Qualifications Associates degree required. Bachelor’s degree preferred.
Active NYS RN licensure required.
Minimum of three (3) years of clinical experience required; Case Management experience preferred.
Proficiency with the Microsoft Office Suite.
Experience interpreting managed care benefit plans and knowledge of government program contracts (Medicare/Medicaid) preferred.
Strong written and verbal communication skills; ability to multitask and work independently.
Deliver efficient, effective, and seamless care to members.
For incumbents aligned to the Federal Employee Program (FEP), Case Management Certification required within three years of hire or moving into this role supporting the FEP LOB.
Equal Opportunity Employer
We are committed to inclusion, diversity, equity, and access. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.