RN Case Manager - Child Services

The RN Case Manager here will be performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs.

Major Job Duties:

• Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. 

• Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.

• Coordinates internal and external resources to meet identified needs.

• Monitors and evaluates effectiveness of the care management plan and modifies as necessary. 

• Interfaces with Medical Directors and Physician Adviso rs on the development of care management treatment plans. 

• Negotiates rates of reimbursement, as applicable. 

• Assists in problem solving with providers, claims or service issues. 

• Assists with development of utilization/care management policies and procedures.