Job Description

The Pediatric Case Manager manages and tracks all pediatric members who require a comprehensive approach to immediate and ongoing care of their complicated illnesses and medical management needs. This position provides members with ongoing case management services due to their chronic and at times debilitating conditions. The Pediatric Case Manager documents interactions with and on behalf of the member throughout service delivery including, but not limited to: care plans, progress notes, assessments, correspondence, and authorizations.

Job Responsibility:
Provide Case Management services to referred members:
* Review, screen, prioritize, and expedite as appropriate all pediatric referrals received
* Identify children with Specials Health Care needs that have a potential diagnosis(s) eligible for the Children Rehabilitative Services Program (CRS) and NICU graduate members that require Pediatric Case Management services
* Perform telephonic, age appropriate assessment of member needs and address these needs to remove any barriers in achieving optimal behavioral health and medical care
* Act as a liaison to facilities, providers and/or members/parents/guardians related to issues in case management and care services
* Encourage members in self-advocacy and self-management  in order to make healthy lifestyle changes
* Educate members/parents/guardians on the importance of good health and following up with the Primary Care Physician on a regular basis
* Review prior authorization/service requests with Medical Director for determination
* Complete member surveys, assessments and care plans
* Request and review medical records
* Provide and coordinate community resources and referrals
* Provide member/parent/guardian education on disease processes
* Conduct initial and follow-up assessments within designated timeframes on NICU discharge notification referrals  on members identified as having highest risk complex case management needs
Assist with any other job duties identified by the department:
* Assist with any reporting/tracking responsibilities
* Assist other departments when necessary to ensure the member’s health care needs are met
* Collaborate with the Interdisciplinary Team to incorporate best practices, assess outcomes and develop individualized care plans
* Develop and monitor the member’s care plan goals for progress and outcomes
* Accurately document members’ case management plans, authorizations, assessment, and levels of care
* Attend case management team meetings, as scheduled
Acts as a liaison between HCA members who have been diagnosed with medical condition(s) which is covered through the Children’s Rehabilitative Services(CRS) Program
* Review pediatric referrals for possible eligible CRS conditions, request supporting medical documentation, and submit applications to CRS for eligible Health Choice members
* Communicate to the PCP and specialty offices HCA termination and CRS enrollment, help members contact the CRS Clinic and schedule future appointments In various clinics as per plan of care
Post-NICU discharge outreach to the parents/families of the NICU graduate

Expected Outcomes:
* Ensure member is transitioned in to case management program when appropriate.
* Ensure overall program goals of the department are met and/or exceeded
* Health Choice staff serve as single point of contact
* Interdisciplinary team is engaged with the member/parent/guardian to create care plans and discharge plans
* Members/parents/guardians understand the difference between emergent and non-emergent services and where to access appropriate levels of care
* Members/parents/guardians utilize the ER in emergencies and PCP offices for routine needs
* Members/parents/guardians understand role of case/disease management to assist them with their healthcare needs
* Authorizations are processed promptly so members obtain timely medical care
* Resources are identified to reduce barriers to receiving care in alternative setting than the ER
* A positive flow of communication with member and provider is maintained to promote goal achievement
* All member/parent/guardian, provider and/or other agency concerns regarding complicated or catastrophic illnesses will be addressed
* Documentation is complete, accurate, following identified protocols and time frames
* Medical Review team makes accurate medical decisions on the requested service
* Smooth transition for newly CRS enrolled members.
* Ensure overall program goals of the department are met and/or exceeded
* Ensure member is transitioned in to case management program when appropriate.

Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment - while still being valued for your individual strengths - Health Choice is the place for you.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled


Professional Competencies (knowledge, skills, and abilities):


Knowledge of Medicare and Medicaid regulations and guidelines preferred

Knowledge of professional and community based resources helpful

Knowledge of medical terminology

Knowledge of CRS and/ or NICU programs preferred

Knowledge and experience in pediatrics


Computer experience necessary

Effective time management skills

Effective interpersonal and communication skills



Ability to use electronic medical record and claims systems

Problem solving abilities

Work cooperatively, positively, and collaboratively in an interdisciplinary team

Work respectfully and positively with members and providers

Ability to handle multiple tasks and prioritize work tasks to adhere to deadlines and identified time frames

Ability to think analytically and make decisions

Handle multiple and changing priorities at a fast pace


Associate’s degree or Bachelor’s degree from an accredited Nursing School


At least two (2) years in a health care setting, pediatric preferred

Experience coordinating patient care

HMO/Managed Care/ Medicare/Medicaid experience preferred

Certification and License:

Active, current, valid, unrestricted Arizona State Registered Nurse (RN) License or LPN License

Application Instructions

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