Care Manager - Pediatric (Remote)

Talantir; Baltimore (MD); Hybrid; USD 72,000 - 143,000; Full time

Job summary

CareFirst BlueCross BlueShield seeks an experienced Nurse Care Manager to support Adult and Pediatric members from a remote location within the greater Baltimore area. Periodic on-site meetings and trainings are required at CareFirst locations.

The role involves developing comprehensive care plans with members and families, coordinating with the interdisciplinary team, and ensuring documentation meets regulatory standards to drive optimal health outcomes and cost-effective care.

Qualifications

• High School Diploma or GED required.
• 5 years clinically related experience in care management, discharge coordination, home health, utilization review, disease management, or direct patient care.
• RN licensure in MD, VA or DC; active/state licensure required.

Responsibilities

• Identify members with acute/complex conditions and develop plans of care with family and care team.
• Collaborate with interdisciplinary team to address medical, behavioral, and social needs.
• Monitor and update plans to reflect stabilization and member self-management.
• Document member data per CareFirst protocols and regulatory standards.

Skills

Clinical care management

Verbal and written communication

Care coordination

Education

High School Diploma or GED

Bachelor's degree in nursing

CCM/ACM certification

Job description

Resp & Qualifications

PURPOSE:

We are looking for an experienced Nurse Care Manager to work remotely from within the greater Baltimore, Maryland metropolitan area with both Adult and Pediatric members. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. Under minimal supervision, the Nurse Care Manager researches and analyzes the Adult and Pediatric member's medical and behavioral health needs and healthcare cost drivers. The Nurse Care Manager works closely with the member / members family and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes.

ESSENTIAL FUNCTIONS:

Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with member, family and providers to develop a comprehensive plan of care to address the members needs at various stages along the care continuum. Identifies relevant CareFirst and community resources and facilitates program, network, and community referrals.

Collaborates with member and the interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address members medical, behavioral and/or social determinant of health needs. Engage members and providers to review and clarify treatment plans ensuring alignment with medical benefits and policies to facilitate care between settings. Monitors, evaluates, and updates plan of care over time focused on member's stabilization and ability to self manage. Ensures member data is documented according to CareFirst application protocol and regulatory standards.

QUALIFICATIONS:

• Education Level: High School Diploma or GED.
• Experience: 5 years clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review, Disease Management or other direct patient care experience.

Preferred Qualifications:

• Bachelors degree in nursing
• CCM/ACM or other RN Board Certified certification in case management. Incumbents not certified at the time of hire must have two years of case management experience and meet requirements to take CCM or ACM exam and successfully achieve the certification within the first year of employment.

Knowledge, Skills and Abilities (KSAs)

• Incumbent must have an advanced knowledge of clinical standards of care and disease processes.
• Must have the ability to produce accurate and comprehensive work products with minimal direction.
• Must be able to triage immediate member health and safety risks.
• Must have a basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g., networks, eligibility, benefits).
• Must have excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
• Must be proficient in the knowledge of available community resources and programs and Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
• Must be able to provide excellent internal and external customer service.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time

Licenses/Certifications:

RN - Registered Nurse - State Licensure And/or Compact State Licensure RN- Registered Nurse in MD, VA or Washington, DC Upon Hire Req.

Salary Range:

$72,216 - $143,429

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Commercial Risk Care Management

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.