[Remote] Pediatric Care Manager - Remote

Note: The job is a remote job and is open to candidates in USA. Blue Cross Blue Shield of Arizona is committed to inspiring health and providing a variety of health insurance products and services. The Pediatric Care Manager role is responsible for promoting continuity of care through collaborative processes, assessing and coordinating care options to meet individual health care needs while ensuring quality and cost-effective outcomes. Responsibilities • Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan. • Answer a diverse and high volume of health insurance related customer calls on a daily basis. • Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc. • Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests. • Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director. • Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries. • Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines. • Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements. • Maintain complete and accurate records per department policy. • Demonstrate ability to apply plan policies and procedures effectively. • When indicated to assist with team/project functions: • Collaborate with team to distribute workload/work tasks; • Monitor and report team tasks; • Communicate team issues and opportunities for improvement to supervisor/manager; • Support/mentor team members. • Participate in continuing education and current development in the field of medicine, behavioral health and managed care at least annually. • The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. • Perform all other duties as assigned. Skills • 2 year(s) of experience in full-time equivalent of direct clinical care to the consumer • Within 4 years of hire as a Care Manager employee must hold a *certification* in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC). • Intermediate PC proficiency • Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones • Intermediate skill in word processing, spreadsheet, and database software • Maintain confidentiality and privacy • Advanced and current clinical knowledge • Practice interpersonal and active listening skills to achieve customer satisfaction • Interpret and translate policies, procedures, programs, and guidelines • Capable of investigative and analytical research • Demonstrated organizational skills with the ability to prioritize tasks and work with multiple priorities • Follow and accept instruction and direction • Establish and maintain working relationships in a collaborative team environment • Apply independent and sound judgment with good problem solving skills • Navigate, gather, input, and maintain data records in multiple system applications • Conflict Resolution • Represent BCBSAZ in the community • 3 year(s) of experience in full-time equivalent of direct clinical care to the consumer (managed care CM experience preferred) • 1-2 year (s) of experience working in a managed care organization • Active and current *certification* in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC). • Advanced PC proficiency • Knowledge of CPT 2018 and ICD-10 coding • Knowledge of managed care, utilization management, and quality management • Working knowledge of McKesson InterQual, MCG, ASAM, or other nationally recognized criteria • Knowledge of a wide range of matters pertaining to the organizations services and operations • Knowledge of health and/or patient education and behavior change techniques Education Requirements • Associate’s Degree in general field of study ***or*** Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D • Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN. • Bachelor's Degree in Nursing or Health and Human Services related field of study Company Overview • Blue Cross Blue Shield of Arizona is a non-profit company that offers health insurance and financial services. It was founded in 1939, and is headquartered in Phoenix, Arizona, USA, with a workforce of 1001-5000 employees. Its website is https://www.azblue.com. Company H1B Sponsorship • Blue Cross Blue Shield of Arizona has a track record of offering H1B sponsorships, with 2 in 2024, 5 in 2023, 2 in 2022, 1 in 2021, 5 in 2020. Please note that this does not guarantee sponsorship for this specific role. Apply tot his job Apply To this Job