Pediatric Care Manager

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25‑year history of providing health insurance that works for our members, no matter their circumstances. Job Summary The Pediatric Clinical Care Manager provides holistic care management services for pediatric members across the continuum of care by conducting clinical assessments, evaluating readiness for behavioral change, and engaging members and their caregivers in the development and achievement of individualized goals. WellSense Health Plan members may include children and adolescents with chronic conditions and complex care needs, including those identified as high‑risk, those experiencing housing instability, and those diagnosed with autism spectrum disorder, other neurodevelopmental or neurodivergent disorders, asthma, and multiple clinical and behavioral comorbidities or special health care needs. The Pediatric Clinical Care Manager works collaboratively with a multidisciplinary team, including internal staff, pediatric providers, clinical vendor partners (behavioral health, pharmacy, etc.), schools, early intervention programs, and community and state agencies, to enhance member and caregiver engagement, promote treatment adherence, and address holistic needs from a medical, developmental, psychosocial, and socioeconomic perspective. The overall objective is to improve health outcomes, reduce total cost of care, and enhance the member and family experience within the health care system. Using telephonic outreach, face‑to‑face visits, assessments, real‑time data, motivational interviewing techniques, and evidence‑based pediatric practices, the Pediatric Clinical Care Manager partners with members, caregivers, and care teams to develop and implement an Individual Care Plan (ICP). The ICP emphasizes asthma management, developmental and behavioral supports, self‑management (as age‑appropriate), caregiver education, care coordination, and access to appropriate psychosocial, socioeconomic, educational, and community‑based supports, with ongoing monitoring and follow‑up. The Pediatric Clinical Care Manager identifies barriers to optimal care and self‑management and works with members, caregivers, and providers to coordinate care throughout the continuum. This includes supporting access to benefits, school‑based services, family support systems, and community resources, with the goal of promoting appropriate utilization of services, preventing avoidable emergency department visits and inpatient admissions related to conditions such as asthma, reducing readmissions, and encouraging adherence to outpatient, preventive, developmental, and specialty care. Face‑to‑face visits are a core component of this role and are routinely conducted in either Western Mass or MetroWest areas in homes, schools, shelters, provider offices, medical facilities, and other mutually agreed‑upon locations. Our Investment In You Full‑time hybrid work Competitive salaries Excellent benefits Key Functions / Responsibilities Supports clinical programs and best practices with the objective of improving pediatric health outcomes, enhancing member safety, reducing medical errors, and promoting preventive health, developmental screening, and wellness activities. Completes general, pediatric, and condition‑specific assessments, including those related to asthma management and neurodevelopmental disorders such as autism spectrum disorder. Determines eligibility for complex care management, disease management, or chronic condition management programs. Collaboratively develops and maintains an individualized care plan focused on member and caregiver goals, including strategies, services, and supports required to achieve both short‑ and long‑term outcomes. Assesses options for care including use of benefits and community resources to update the care plan as needed. Assists members and families in accessing benefits, school‑based supports (e.g., IEP/504 resources), family support systems, and community‑based resources. Utilizes motivational interviewing techniques to engage caregivers and, when appropriate, pediatric members, to promote health behavior change and adherence to treatment plans. Supports members and caregivers in developing self‑management and care coordination skills appropriate to developmental level. Acts as a liaison and member advocate between the member and their family, legal guardian, physician, and facilities/agencies. Identifies and addresses barriers to optimal self‑management and caregiver support and coordinates care across the health care continuum. Promotes collaboration between caregivers, pediatric primary care providers, specialists, schools, and other members of the care team. Participates in multidisciplinary rounds, case reviews, and team meetings. Facilitates interdisciplinary teamwork to ensure coordination of care through participation in rounds, team meetings, and clinical reviews. Communicates with physicians, hospitals, ancillary providers and community agencies as needed to communicate or receive essential clinical and psychosocial information related to a member’s care. Refers members to social care management, behavioral health care management, community health workers, and developmental or autism‑specific services based on clinical need. Applies evidence‑based guidelines to educate members and caregivers about asthma, autism spectrum disorder, and other pediatric conditions. Utilizes standardized educational materials appropriate to pediatric developmental stage, caregiver literacy, and language needs. Coordinates resources to address social determinants of health, including psychosocial, socioeconomic, developmental, and educational needs. Manages care transitions, including pre‑admission and post‑discharge follow‑up, ensuring appointments, asthma action plan adherence, medication reconciliation, and compliance with discharge plans. Leverages real‑time data and available electronic medical records to inform care planning and coordination. Reviews medical and pharmacy utilization data to promote medication adherence, including inhaler use and asthma action plans. Monitors laboratory results, appointments, developmental evaluations, and other clinical data to support effective care coordination. Continuously evaluates care management effectiveness and updates the care plan accordingly. Conducts frequent face‑to‑face visits in Hampden and Suffolk counties in homes, schools, provider offices, hospitals, shelters, and community settings, as appropriate. Maintains reliable transportation to support in‑person pediatric care management activities within assigned regions. Completes accurate and timely documentation in accordance with contractual requirements, internal policies, and NCQA standards. Demonstrates knowledge of contractual requirements across product lines and provides cross‑coverage as needed. Adheres to departmental and organizational policies and procedures. Maintains HIPAA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues. Ensures compliance with all state and federal regulations in day‑to‑day activities. Assists with staff training and mentoring as needed. Other duties as assigned. Supervision Exercised None Supervision Received Regularly scheduled meetings with Manager of Care Management Qualifications Education Required Bachelor’s Degree in Nursing or Associate’s degree in Nursing and relevant work experience. Experience Required 3 years of experience in pediatric clinical care, home health care, or a managed care environment. 3 years of clinical experience with pediatric members with chronic or complex conditions, including asthma and neurodevelopmental disorders. Experience Preferred / Desirable 2 years of experience with case management, care coordination, and/or discharge planning. Experience working with Medicaid recipients and community‑based and school‑based services. Experience with FACETS, Jiva, or other healthcare database. Certified Case Manager (CCM) certification preferred. Required Licensure, Certification or Conditions of Employment Successful completion of pre‑employment background check. Current, unrestricted, Registered Nurse license in Massachusetts. Regular and reliable transportation and the ability to conduct face‑to‑face appointments with members, providers, community and state agencies in Western MA and MetroWest Regions. Competencies, Skills, and Attributes Strong motivational interviewing skills. Strong verbal and written communication skills. Ability to effectively collaborate with health care providers and all members of the multidisciplinary team. Strong technical skills and ability to document in the plan’s care management documentation system in real‑time when meeting with members and providers in‑person or by phone. Demonstrated organizational and time‑management skills. Ability to function effectively in a fast‑paced, dynamic environment with competing priorities. Experience with Microsoft Office application, particularly MS Outlook and MS Word and Excel. Strong analytical and clinical problem‑solving skills. Working Conditions and Physical Effort Regular and reliable attendance is an essential function of the position. Work may be performed in a typical interior/office work environment or in a home office except when conducting face‑to‑face visits. Face‑to‑face visits may be conducted in a member’s home, shelters, physician practices, hospitals, or at a mutually agreed upon location between the member and the care manager and also with community and state agencies, as appropriate. No or very limited physical effort required. No or very limited exposure to physical risk. Fast‑paced office environment. Travel required up to 50% of the time. Compensation Range 74,000–107,000USD per year. This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business and organizational needs, internal equity, and market competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing. Note This range is based on Boston‑area data, and is subject to modification based on geographic location. About WellSense WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high‑quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability, or protected veteran status. WellSense participates in the E‑Verify program to electronically verify the employment eligibility of newly hired employees. #J-18808-Ljbffr