Complex Case Manager RN - Pediatrics (Remote)

Lensa; Denver (CO); Remote; USD 57,000 - 108,000; Full time

Job summary

A leading healthcare provider is seeking a Complex Case Manager RN specializing in Pediatrics. This remote role involves assessing health needs, creating care plans, and managing a caseload of members to improve health outcomes. Candidates should have significant clinical experience and strong communication skills. Join a team dedicated to enhancing patient care and achieving quality outcomes.

Qualifications

• 7 years in clinical, case management, or health insurance required.
• Pediatric experience preferred.

Responsibilities

• Oversee members by assessing health needs and identifying interventions.
• Create and implement care plans to improve health outcomes.
• Achieve target goals and document all activities.

Skills

Effective communication

Negotiation

Interpersonal skills

Knowledge of disease processes

Healthcare costs

Organizational skills

Time management skills

Self-directed

Education

High School Diploma/GED

Bachelor's Degree in Nursing

Tools

MS Excel

Job description

Complex Case Manager RN - Pediatrics (Remote)

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Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This role involves primary ownership and oversight of a specified panel of members with varying health statuses and clinical needs. The incumbent assesses health management needs, uses data and analytics alongside clinical judgment to identify appropriate interventions, and manages a caseload of enrolled members. Responsibilities include developing care plans, encouraging behavioral changes, addressing barriers, coordinating care, and utilizing resources to help members achieve health goals. The role also involves monitoring and improving quality outcomes across clinical, financial, and functional metrics.

ESSENTIAL RESPONSIBILITIES

• Oversee members by assessing health needs, identifying interventions, and referring to resources.
• Create and implement care plans to meet members' needs and improve health outcomes.
• Achieve target goals and document all activities in compliance with standards.
• Stay current with regulatory and practice standards, including CMS and ACMA guidelines.
• Perform other duties as assigned.

Education

• Required: High School Diploma/GED

• Preferred: Bachelor's Degree in Nursing

Experience

• Required: 7 years in clinical, case management, disease management, provider operations, or health insurance.

• Preferred: Pediatric experience, training in CBT, motivational interviewing, or DBT, experience with diverse populations, and cultural competency understanding.

Licenses and Certifications

• Required: RN license in PA, WV, DE, or NY (others to be obtained within 6 months).

• Preferred: Certification in Case Management.

Skills

• Effective communication, negotiation, and interpersonal skills.
• Knowledge of disease processes and healthcare costs.
• Proficiency in MS Excel and data analysis.
• Organizational and time management skills.
• Self-directed with the ability to work independently.

Additional Information

Travel requirement: 0-25%

Position type: Office-based

Physical demands include occasional lifting up to 25 pounds.

Compliance with HIPAA, privacy policies, and company conduct standards is mandatory.

Pay Range

Minimum: $57,700; Maximum: $107,800

Note: Salary depends on qualifications, experience, and location.