Case Manager, Pediatrics (Registered Nurse)
Overview and role context provided by the case management program across pediatric populations, aligning with departmental, corporate, NYS DOH, CMS, FEP and NCQA accreditation standards. The Case Manager uses a systematic approach to identify members, educate and support, coordinate care, and review treatment options in collaboration with providers and community resources.
Responsibilities
Manage physical health member clinical programs in line with CMSA, NCQA, departmental policies, NYS DOH, CMS regulations, FEP (if applicable), and other regulatory requirements.
Maintain confidentiality and conduct information management per policy; implement the Case Management Process (identification, opening, assessment, education, care planning, interventions, outcomes measurement, case closure, and reviews).
Screen members within defined populations, apply case management criteria and professional judgment to determine appropriateness for services.
Open cases promptly; use motivational interviewing to disclose essential case management information to members to support health goals.
Collaborate with members’ physicians and other health care providers to assess needs, develop interdisciplinary care plans, coordinate services, evaluate effectiveness, and adjust plans as needed.
Educate members and caregivers to address knowledge deficits; set objectives, goals, and actions to meet health goals and overcome barriers.
Provide resources and assistance across the continuum of care; maintain up-to-date community resources and serve as a liaison between providers and community resources.
Participate in inter-disciplinary coordination (Utilization Management, Quality, Behavioral Health, Pharmacy, Dietetics, Respiratory Therapy) to ensure quality care.
Engage in continuing education to meet policy and certification standards; promote participation in preventive health and digital health programs.
Collaborate with other Case Managers to ensure continuity and coordination of care; participate in value-based payment programs when applicable.
Maintain high professional integrity, privacy standards, and support the organization's mission and values.
May participate in orientation of new staff; maintain regular attendance; perform other duties as assigned.
Level II and Level III Accountabilities
Level II: Handle all member clinical condition management programs; assist with process improvements; mentor junior staff; meet productivity and audit metrics; coordinate with members and providers independently; manage larger caseloads; demonstrate leadership; participate in staff orientation.
Level III: Process management and documentation; identify and develop improved processes; act as subject matter expert; mentor staff; provide backup to supervisor; ensure regulatory compliance; oversee department quality and education needs.
Active NYS RN or Registered Dietitian or Physical Therapist licensure required.
Minimum of three (3) years of clinical experience; Case Management experience preferred.
Proficiency with 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) line of business, Case Management Certification required within three years of hire/move to this role supporting FEP.
Level II: Minimum 2 years in a case management position; Case Management Certification preferred; ability to escalate to management; proficiency in related technology and documentation; meet performance metrics.
Level III: At least 5 years in Case Management or equivalent; Case Management Certification required; broad understanding across UM and CM; ability to lead training and handle complex assignments; demonstrate presentation skills.
Physical Requirements
Ability to travel and work long hours on a computer; may require flexible hours for member discussions.
One Mission. One Vision. One I.D.E.A. One you. We are committed to inclusion and health equity.
Our Company Culture and Equal Opportunity Employer statements apply. Reasonable accommodations for qualified individuals under the Americans with Disabilities Act (ADA) will be provided as needed.
Compensation and Benefits
Compensation ranges by level (Level I-III) are provided; actual salary varies by experience and internal equity.
Benefits may include health/dental insurance, retirement plans, wellness programs, paid time off, and paid holidays.
Please note: Remote work opportunities may be available on a case-by-case basis. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.