Medical Case Manager - Pediatric Shift Care (RN) Remote
Company :
Highmark Inc. Job Description :
JOB SUMMARY
The Pediatric Shift Care Case Manager plays a crucial role in supporting pediatric members and their families who are receiving in-home nursing and aide care (Shift Care services). They act as a central point of contact within Highmark Wholecare, handling case management, needs assessment, resource coordination, and benefit-related inquiries.
ESSENTIAL RESPONSIBILITIES
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Manage a caseload of members with moderate complexity health needs.
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Assess members’ health status, needs, and available resources.
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Develop individualized care plans in collaboration with members, physicians, and other healthcare providers.
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Implement and coordinate care plans, ensuring access to appropriate services and resources.
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Develop and implement care plans with minimal guidance.
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Coordinate referrals to specialists and community resources.
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Monitor member progress toward goals and adjust care plans as needed.
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Evaluate the effectiveness of interventions and services.
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Act as an advocate and liaison to meet a member's individual health care needs by assessing, planning, implementing, coordinating, monitoring and evaluating options and services. This is accomplished by using communication and available resources to promote quality, cost-effective outcomes in accordance with available contract benefits.
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Work collaboratively and communicate clearly and professionally with physicians, providers, co-workers and other members of the health care team to carry out the established plan of care.
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Ensure all activities are documented and conducted in compliance with applicable business process requirements, company policies, regulatory requirements and accreditation standards.
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Identify areas for potential cost savings, quality improvement and workflow efficiencies.
- Other duties as assigned or requested.
EXPERIENCE
Required
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3 years of experience in any combination of clinical, case/utilization management, and/or disease condition management experience, or provider operations and/or health insurance experience with RN licensure or a Master’s degree OR; 5 years’ experience with a Bachelor’s in Social Work
Preferred
- Registered Nurse (RN)
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Medicaid managed care and/or Medicare experience
- Experience in Pediatric care
- Certified Case Manager
- Knowledge of assessments and care plans
SKILLS
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Strong assessment and care planning skills.
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Ability to work independently and as part of a team.
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Proficiency in using Microsoft office suite, case management software and electronic health records.
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Understanding of healthcare systems and case management principles
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Bilingual English/Spanish language skills preferred
EDUCATION
Required
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Bachelor’s degree in nursing or RN licensure or Master’s degree in Social Work, Counseling, or related field OR Bachelor’s degree in Social Work
Preferred
- None
LICENSES or CERTIFICATIONS
Required
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Licensed Social Worker (LSW)-Non-Specific - State (OR) Licensed Professional Counselor (LPC) - Non-Specific State (OR) Licensed Bachelors Social Worker (LBSW) (OR) Licensed Clinical Social Worker (LCSW) - Non-Specific (OR) Licensed Master Social Worker (LMSW) Non-Specific (OR) Licensed Graduate Social Worker (LGSW) (OR) Licensed Certified Social Worker (LCSW) (OR) Current State RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Incumbents in the role prior to 1/1/25 who are not currently licensed must obtain licensure by 12/31/27.
Preferred
- Certified Case Manager (CCM)
- Pennsylvania RN license
Language (Other than English):
None
Travel Required:
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-Based or Remote Position
Physical work site required
Occasionally
Disclaimer: The job description has been designed to indicate the general nature and essential duties and re