CareFirst Careers

Pediatrics Case Manager II

Resp & Qualifications

Purpose: The Pediatrics Case Manager II performs the collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual member and their family’s comprehensive health needs through communication and available resources to promote quality cost effective outcomes, in alignment with the standards of the Case Management Society of America (CMSA). The CareFirst case management process includes care coordination for the most acute, complex and catastrophic conditions, and collaboration with appropriate members of the external health care team and internal professionals with the CareFirst Hospital Transition of Care and PCMH programs. The Pediatrics Case Manager II utilizes a full array of care coordination resources with the Total Cost & Care Improvement (TCCI) program drawing on clinical assessment and analytical thinking skills to actively and continuously facilitate a comprehensive treatment plan to stabilize the member and ensure appropriate services.

Principle Accountabilities:Under the general direction of the Supervisor of Case Management the incumbent’s accountabilities include, but are not limited to the following (specific goals for Case Management Department are determined on an annual basis in accordance with divisional goals as outlined and approved the by the executive leadership team):


  • Identification/Risk Stratification: Engages members utilizing motivational interviewing as appropriate into the case management program (outreach and successful enrollment) using diagnostic cost group classifications reports, which identify the relative risk score and illness burden. The pediatric case manager identifies members with catastrophic diagnosis and health care users with significant health care costs in band one of the illness burden pyramid.
  • Assessment: Conducts and documents a comprehensive discipline specific assessment of the member’s clinical condition, health, and  psychosocial behavioral needs, including health literacy and deficits.  Identifies the main catastrophic and comorbid related issues requiring intervention and action. Completes the assessment which includes current clinical/medical condition, past medical history, a review of tobacco/substance and alcohol use, past or current mental health or cognitive issues, any visual or hearing needs, cultural and linguistic needs/preferences or limitations, nutrition and diet, occupational and financial concerns, social support system, and medications. Determines if member clinical state warrants referral to appropriate TCCI programs which provide additional support services to the member in achieving optimum wellness and health. This is includes but is not limited to: Patient Centered Medical Home (PCMH); Home Based Services; Enhanced Monitoring; Expert Consult; Substance Abuse & Behavioral Health; Comprehensive Medication Review; Pharmacy Coordination for Specialty Pharmacy; and various Community Based Programs (Cardiac Rehab; Skilled Nursing Facilities; Hospice/Palliative Care; Diabetes Education; etc.).
  • Planning: Develops individualized care plans that include prioritized goals to address the needs identified during the assessment for every member. Develops the care plan in collaboration with the member, caregiver(s), physician, discharge planner,  Hospital Transition of Care (HTC) nurse, Local Care Coordination (LCC) and appropriate TCCI program partners and other healthcare providers/vendors. Goals developed are prioritized, action-oriented and time-specific to stabilize the complicated health care condition. Ensures that care plans address the care coordination and educational needs of the member, conducts benefit and contract interpretation and analysis as appropriate, and applies the appropriate current resource utilization to address the clinical and other needs.
  • Care Coordination and Facilitation of Communication: Executes the transition of care which involves moving the member from one healthcare practitioner and/or setting to another as their healthcare needs change, utilizing TCCI and community programs as appropriate to meet the member’s needs. Implements and oversees the agreed upon plan of care in conjunction with TCCI and community partners and reviews complex cases (complex clinical needs, medical policy, complex benefit structure, FDA treatment, clinical trials and drugs) with the appropriate medical director. Proactively identifies discharge care needs and identifies and provides educational and community resources, support groups, pharmacy programs, financial assistance and alternative payers (MA, WIC, Model Waiver, COBRA, SSDI etc.). Manages the clinical and administrative responsibilities effectively so that cases are followed-up and closed timely and the case managers balances the opening of new cases, the following up of active case and the closure of cases where member has achieved goals. This balance ensures that members are receiving the appropriate services in a timely manner.
  • Monitoring: Assesses the member’s ongoing care needs and progress toward goals throughout the case duration and makes revisions as needed to address changes in the members condition, lack of response to the care plan, preference changes, and transitions in care settings. Maintains at least weekly contact with the member to assess progress. Completes documentation that reflects the necessary communication and follow up throughout the care continuum with the member, caregiver, physicians, and other health care providers to ensure the member’s progression in meeting the established care plan goals.
  • Outcomes Management: Evaluates the extent to which the established goals in the plan of care have been achieved. Completes a monthly member-specific cost savings to demonstrate the efficacy, quality, and cost-effectiveness of the case management interventions in conjunction with the results of the member satisfaction survey.  Completes a case closure summary that contains quality outcomes for every case.

2. Administrative Proficiency

  • Utilizes a web-based medical record platform to complete accurate, timely documentation of clinical summary, comprehensive assessment, individualized care plan with identified problems and goals, case management interventions including care coordination and collaboration with health care providers and appropriate TCCI programs
  • Performs care coordination and documentation thereof with an  acceptable level quality audit score
  • Completes accurate updates to Access Data Base to enable daily referral and reporting functions and correspondence generation management
  • Assists in claims inquiries and resolution by connecting the member or other inquiring party with the appropriate internal department
  • Confirms member eligibility and available benefits utilizing CareFirst systems and platforms (FEP Direct, CareFirst Direct, Facets, NASCO, Blue Web) Interprets benefit plans and how they apply to a member’s care coordination needs; Reviews employer group contracts to determine steps necessary to secure services and/or determine alternative solutions to meet member’s clinical needs; Educates members about special aspects of benefit plans such as cost share waivers and connects members to the appropriate CareFirst customer service representative for additional details on specialize benefit protocols.
  • Effectively utilizes the CareFirst systems, contract and medical policy knowledge to address member issues and help member progress toward goals.
  • Participates in the preparation and on-site reviews related to Employer Group and Accreditation Audits.
  • Maintains a working knowledgeable of federal/state mandates as they apply to various plan contracts
  • Completes documentation review and self-audit as assigned by management
  • Utilizes Apollo Guidelines to effectively complete discharge planning (and length of stay review for FEP Line of Business only)
  • Adheres to the NCQA Case Management Standards and the CMSA Standards of Practice for Case Management
  • Maintains confidentiality of patient information according to HIPAA and departmental policies

3. Departmental Activities
Plays an active role in the day to day tasks associated with being a member of the FEP Case Management department.

  • Completes mandatory training
  • Actively participates in team huddles and contributes to the clinical learning
  • Keeps current on clinical knowledge via self-directed learning
  •  Effectively escalates issues and/or system issues to supervisor
  • Collaborates with other departments HTC/PCMH/Pre-Service/Appeals
  • Other duties as assigned

SCOPE DATA: This position is responsible for ensuring the quality of health care services for target population. Caseload and productivity are set and adjusted to reflect the senior level of this position.

Case Managers are actively involved in the coordination of care for members, often interfacing with members and their families as well as multiple physicians and/or healthcare providers. Weekly contact with the member is expected and when a third party service provider is engaged through one of the TCCI programs, the case manager is expected to be actively involved in the coordination of care before, during and after the intervention.  Case Managers are expected to  be proficient in their knowledge of the many TCCI programs, regularly make referrals to them and stay actively involved in the coordination of the member’s care and subsequent progress while a member is engaged in one or more TCCI programs.  The TCCI programs include but are not limited to: Patient Centered Medical Home (PCMH); Home Based Services; Enhanced Monitoring; Expert Consult; Substance Abuse & Behavioral Health; Comprehensive Medication Review; Pharmacy Coordination for Specialty Pharmacy; and various Community Based Programs (Cardiac Rehab; Skilled Nursing Facilities; Hospice/Palliative Care; Diabetes Education; etc.).


  • Current RN license with a minimum of  4 – 8 years of clinical experience in medical-surgical, community/home health care, case management, and equivalent experience reviewing patient medical care and services. and one or more of the following specialty fields
  • Special Needs/High Risk Pediatrics
  • Pediatric Oncology or Adult Oncology
  • High Risk Pregnancy
  • Complex Medical Illnesses (e.g MS, Lupus, Ulcerative Colitis)
  • Palliative Care/Hospice
  • Trauma/Rehab
  • Minimum of 2 years of Case Management experience or equivalent related work experience
  • In-depth knowledge of current standard of medical practice and insurance benefit structures to facilitate medical review decisions and interpret contract benefits and managed care guidelines.
  • A strong knowledge of Case Management process, standards, and understanding of managed care. 
  • Detailed knowledge and competency in all types of medical necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care, and home health care.
  • A strong knowledge and expertise in case managing complex cases with minimal supervision. 
  • Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues. 
  • Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
  • Ability to work independently and as part of a team.
  • Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed.
  • Proficient in the use of web-based technology and Microsoft Office applications such as Word and Excel.
  • Ability to perform critical clinical analysis and build relationships with members/patients in order to effect change promote positive outcomes and empower member/family to be actively engaged in their treatment outcomes.
  • Proven experience in providing excellent customer service to external and internal customers. 
  • Excellent analytical and problem solving skills in order to judge medical necessity and appropriateness of patient services and treatments on a case by case basis.
  • Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.  Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.   Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.


  • BSN or CCM
  • Experience coordinating care by telephone.


Department: FEP Case Management

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before:2/22/2019

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

The physical demands described here are representative of those that must be met by the incumbent to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.
• Must be able to work in an office setting, primarily seated talking on the telephone while performing duties for a minimum of 8 hours per work day.
• Occasional walking or standing is required.  Lift weight up to 25 pounds on occasion.
• Hands are regularly used to write, type, key and handle or feel small controls and objects. 
• Must be able to type and to speak on the telephone simultaneously.
• Have the ability to verbally communicate effectively.
• Auditory ability to actively listen.
• Travel to and from the office is required.  Travel to other CareFirst locations may occasionally be required.  Must provide own transportation.

Equal Employment Opportunity:  We are an Equal Employment Opportunity/Affirmative Action Employer and ADA compliant.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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