Highmark Inc.
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
Manage a caseload of members with moderate complexity health needs.
Assess members’ health status, needs, and available resources.
Develop individualized care plans in collaboration with members, physicians, and other healthcare providers.
Implement and coordinate care plans, ensuring access to appropriate services and resources.
Develop and implement care plans with minimal guidance.
Coordinate referrals to specialists and community resources.
Monitor member progress toward goals and adjust care plans as needed.
Evaluate the effectiveness of interventions and services.
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.
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.
Ensure all activities are documented and conducted in compliance with applicable business process requirements, company policies, regulatory requirements and accreditation standards.
Identify areas for potential cost savings, quality improvement and workflow efficiencies.
Other duties as assigned or requested.
EXPERIENCE
Required
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)
Medicaid managed care and/or Medicare experience
Experience in Pediatric care
Certified Case Manager
Knowledge of assessments and care plans
SKILLS
Strong assessment and care planning skills.
Ability to work independently and as part of a team.
Proficiency in using Microsoft office suite, case management software and electronic health records.
Understanding of healthcare systems and case management principles
Bilingual English/Spanish language skills preferred
EDUCATION
Required
Preferred
LICENSES or CERTIFICATIONS
Required
Preferred
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 responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$72,700.00
Pay Range Maximum:
$116,600.00
Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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