Job Description

HARD Requirements:

• RN with 5+ years of experience
• OBGYN experience 1+ years
• 1+ years of experience care management
• Medicaid experience
• AHCCCS experience is highly preferred

Job Description:

This position provides comprehensive care coordination for patients as assigned. This position assesses the patients plan of care and develops, implements, monitors, and documents the utilization of resources and progress of the patient through their care, facilitating options and services to meet the patients health care needs. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This position is accountable for the quality of clinical services delivered by them and others and identifies/resolves barriers that may hinder effective patient care.

As a Registered Nurse in Obstetrics, you will serve as a Case Manager for approximately 120 members identified with high-risk pregnancies. You will conduct 15–20 outreach calls daily to educate members on maintaining a healthy pregnancy. You will deliver case management services in accordance with NCQA standards, ensuring a holistic approach that encompasses medical, behavioral, and social factors impacting the member's health.

Additional Requirements:

1. Manages individual patients across the health care continuum to achieve the optimal clinical, financial, operational, and satisfaction outcomes.

2. Acts in a leadership function with process improvement activities for populations of patients to achieve the optimal clinical, financial, operational, and satisfaction outcomes.

3. Acts in a leadership function to collaboratively develop and manage the interdisciplinary patient discharge plan. Effectively communicates the plan across the continuum of care.

4. Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes. Assesses patient admissions and continued stay utilizing standard criteria. Identifies issues that may delay patient discharge and facilitates resolution of these issues.

5. Establishes and promotes a collaborative relationship with physicians, payers, and other members of the health care team. Collects and communicates pertinent, timely information to payers and others to fulfill utilization and regulatory requirements.

6. Educates internal members of the health care team on case management and managed care concepts. Facilitates integration of concepts into daily practice.

7. May supervise other staff.

8. Has freedom to determine how to best accomplish functions within established procedures. Confers with supervisor on any unusual situations. Positions are entity based with no budgetary responsibility. Internal customers: All levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External Customers: Physicians and their office staff, payers, community agencies, provider networks, and regulatory agencies.

Job Tags

Similar Jobs