The Case Manager conducts face-to-face visits for members in the pediatric population (0-21) using assessment tools to evaluate medical needs and facilitate overall wellness. Responsibilities also include developing care plans, authorizing cost-effective services, attending interdisciplinary meetings, and ensuring safe discharges with appropriate services.

The Case Manager conducts face-to-face visits for pediatric members (0-21) in Texas to assess medical needs, facilitate wellness, and develop care plans in collaboration with the care team. Responsibilities also include advocating for members, ensuring safe discharge with appropriate services, authorizing cost-effective services, and maintaining accurate documentation in the electronic health record.

The role involves providing prospective, retrospective, and concurrent utilization reviews for Southern CA ministries, which includes conducting clinical reviews and reviewing medical records daily upon admission for all payers. This requires managing a diverse workload efficiently in a fast-paced regulatory environment while demonstrating strong clinical knowledge in utilization management and medical necessity.

The nurse will telephonically coordinate wellness and disease management for conditions like diabetes, asthma, and hypertension, comparing patient care against national guidelines. Key duties include developing individual care plans, assisting patients with provider access and referrals, and documenting all interventions.