PH/Care Coord, CaseMang, MC Pediatric Program

Population Health/Concierge Care Coordination (C3), Pediatric Rn Case Manager, Medically Complex Pediatric Programs The Pediatric RN Case Manager is responsible for providing comprehensive care management and coordination for medically complex pediatric members enrolled in the Concierge Care Coordination (C3) Program. The Pediatric RN Case Manager serves as a primary care coordination resource for members and their families/caregivers, supporting continuity of care across providers, specialists, healthcare settings, and community-based services. This position conducts comprehensive assessments, develops and monitors individualized care plans, identifies and addresses barriers to care, and provides ongoing clinical follow-up, education, and support based on the member's medical, behavioral, developmental, and social needs. The Pediatric RN Care Manager collaborates with families/caregivers, providers, multidisciplinary care teams, and community resources to facilitate access to appropriate services and promote safe, coordinated, and effective care. The Pediatric RN Care Manager is also responsible for maintaining and validating required program information and supporting accurate and timely reporting for the medically complex pediatric population in accordance with applicable state, contractual, and departmental requirements. The Pediatric RN Care Manager supports timely identification of changes in condition, transitions of care, gaps in care, and other needs requiring intervention, with a focus on improving health outcomes, supporting families, reducing avoidable utilization, and enhancing the quality of life of medically complex pediatric members. Essential Duties and Responsibilities: Pediatric Assessment & Individualized Care Planning Conduct comprehensive assessments of medically complex pediatric members to identify medical, behavioral, developmental, psychosocial, educational, and social needs, barriers to care, and caregiver support needs. Develop and maintain individualized, family-centered care plans in collaboration with members, families/caregivers, providers, and the multidisciplinary care team. Establish measurable goals and interventions based on identified needs, member and family priorities, and the established plan of care. Review and update assessments and care plans based on changes in condition, care needs, services, or other applicable program requirements. Identify gaps in care, barriers to treatment, and other needs requiring intervention and coordinate appropriate follow-up. Complex Care Management & Ongoing Monitoring Provide ongoing care management and clinical follow-up for medically complex pediatric members based on individual needs, risk, and applicable program requirements. Monitor changes in medical condition, treatment plans, medications, utilization, services, and other factors that may impact the member's health or care needs. Review relevant clinical information and healthcare utilization to identify changes in condition, emerging needs, gaps in care, or opportunities for intervention. Coordinate timely follow-up following in accordance with department procedures for emergency department visits, hospitalizations, and other significant changes in the member's health status or care needs. Identify and address barriers to recommended care, treatment plans, appointments, medications, services, and other healthcare needs. Escalate significant clinical concerns, changes in condition, quality-of-care concerns, or other issues requiring additional review to appropriate clinical leadership or the Medical Director. Care Coordination, Family Support & Collaboration Serve as a primary care coordination resource for medically complex pediatric members and their families/caregivers, facilitating communication and continuity of care across providers, specialists, healthcare settings, and services. Coordinate with primary care providers, specialists, hospitals, home health providers, therapy providers, medical equipment providers, community resources, and other members of the care team as appropriate to the member's needs. Support safe and effective transitions of care following hospitalization, changes in level of care, or transitions between healthcare settings and services. Educate and support members and families/caregivers regarding the care plan, healthcare needs, available resources, and strategies to promote effective management of the member's condition. Lead and facilitate multidisciplinary care conferences and collaborate with internal and external stakeholders when complex medical, behavioral, social, or care coordination needs require additional intervention. Assess caregiver and social barriers that may affect the member's care and refer and coordinate with appropriate resources to address identified needs. Conduct or participate in-home or community-based assessments in accordance with contractual requirements to support evaluation of the member's care needs, safety, services, or transition planning. Documentation, Reporting & Program Requirements Maintain complete, accurate, and timely documentation of assessments, care plans, interventions, member/family interactions, provider coordination, and other care management activities in accordance with departmental and program requirements. Maintain accurate and current clinical and program information for the medically complex pediatric population to support applicable state, contractual, and departmental reporting requirements. Complete required recurring and ad hoc reporting for medically complex pediatric members within established timeframes. Review, validate, and reconcile member-level information and supporting documentation to ensure accuracy and completeness prior to submission of required reports. Identify and resolve discrepancies, missing information, or documentation gaps and coordinate with appropriate stakeholders as needed. Maintain supporting documentation necessary to substantiate reported information and support applicable program, audit, or regulatory review. Quality, Compliance & Program Support Perform care management activities in accordance with applicable Medicaid contractual requirements, departmental policies and procedures, accreditation standards, and established clinical guidelines. Maintain member confidentiality and protect health information in accordance with HIPAA and organizational requirements. Participate in departmental case reviews, multidisciplinary discussions, training, quality improvement activities, and other initiatives supporting the medically complex pediatric program. Identify recurring member, provider, service, or operational barriers affecting the medically complex pediatric population and communicate concerns and opportunities for improvement to departmental leadership. Perform other job-related duties, projects, and assignments as directed by departmental leadership. This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management. Qualifications: Education: Bachelor’s degree in Nursing (required). Licensure/Certifications: Current unrestricted Florida Registered Nurse (RN) (required). Certified Case Manager (CCM) (preferred). Experience: At least two (2) years’ experience working with pediatric populations (required). Experience caring for medically complex children, children with special healthcare needs, or pediatric patients with multiple chronic conditions preferred. Experience leading multidisciplinary teams. Experience in care management, case management, care coordination, population health, or a managed care/health plan setting preferred. Experience collaborating with multidisciplinary healthcare teams and coordinating care across providers, specialists, healthcare settings, and services preferred. Knowledge of Medicaid, managed care, and applicable healthcare regulatory and accreditation requirements preferred. Skills and Abilities: Strong pediatric clinical assessment and critical-thinking skills, with the ability identify appropriate care coordination needs. Ability to assess and coordinate complex medical, behavioral, developmental, psychosocial, and social needs of pediatric members and their families/caregivers. Strong care management and care planning skills, including the ability to develop, implement, monitor, and update individualized, family-centered care plans. Ability to effectively coordinate care and communicate across primary care providers, specialists, hospitals, ancillary providers, community resources, and multidisciplinary care teams. Strong member and family engagement, education, and communication skills, with the ability to communicate complex healthcare information in a clear and supportive manner. Strong clinical judgment, problem-solving, and decision-making skills, including the ability to identify concerns requiring escalation or additional clinical review. Excellent written, verbal, interpersonal, and documentation skills. Strong organizational and time-management skills with the ability to manage a caseload of medically complex pediatric members and multiple competing priorities. Strong attention to detail with the ability to review, validate, and reconcile clinical and program information to support accurate and timely reporting. Ability to work independently while collaborating effectively with departmental leadership, multidisciplinary teams, providers, and other internal and external stakeholders. Proficiency with Microsoft Office applications and electronic health record/care management systems. Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. A reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion. Background Screening Notice: In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse. The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants. Additional information is available at: 🔗 https://info.flclearinghouse.com