Medical Case Manager - Pediatric Shift Care (RN) (Pediatrics)

Location: Remote or office-based in Pennsylvania; occasional physical work site required

Company

hirify.global provides health insurance and healthcare services, including member-focused care coordination through Highmark Wholecare.

What you will do

• Manage a caseload of pediatric members with moderately complex health needs receiving in-home nursing and aide care.
• Assess member health status, needs, available resources, and progress toward care goals.
• Develop and implement individualized care plans with members, physicians, and healthcare providers.
• Coordinate referrals, services, benefits, and community resources while monitoring intervention effectiveness.
• Advocate for members and communicate with physicians, providers, coworkers, and healthcare teams.
• Document activities in compliance with business processes, company policies, regulatory requirements, and accreditation standards.

Requirements

• At least 3 years of combined clinical, case or utilization management, disease management, provider operations, or health insurance experience with RN licensure or a master's degree; alternatively, 5 years of experience with a bachelor's degree in social work.
• Bachelor's degree in nursing, RN licensure, or a master's degree in social work, counseling, or a related field; alternatively, a bachelor's degree in social work.
• Current state RN licensure, enhanced Nurse Licensure Compact multi-state licensure, or one of the listed social work or counseling licenses is required.
• Strong assessment and care-planning skills, knowledge of healthcare systems and case management principles, and the ability to work independently and collaboratively.
• Proficiency with Microsoft Office, case management software, and electronic health records.
• Must work in Pennsylvania; travel is 0%–25% and occasional physical work-site presence may be required.

Nice to have

• Registered Nurse experience in Medicaid managed care or Medicare.
• Pediatric care experience.
• Certified Case Manager credential.
• Pennsylvania RN license.
• Bilingual English and Spanish language skills.

Culture & Benefits

• Remote or office-based work arrangement.
• Work focused on quality, cost-effective outcomes and member advocacy.
• Compliance with HIPAA, privacy, information security, and business-conduct standards.
• Work involves coordination across physicians, providers, coworkers, and healthcare teams.