Highmark Health Maternity Complex Case Manager RN in Boston, Massachusetts
Job Description :
This job has primary ownership and oversight over a specified panel of maternity and high-risk maternity members that range in health status/severity and clinical needs. The incumbent assesses health management needs of the assigned member panel and utilizing data/analytics in conjunction with professional clinical judgement to identify the right clinical intervention for each member. The incumbent will be supported by a multi-disciplinary team and will use clinical judgment to refer members to appropriate multi-disciplinary resources. In addition to identifying the appropriate clinical interventions and referrals, the incumbent will manage an active case load of members in his/her panel that are enrolled in case management. The incumbent conducts outreach to members enrolled in case management including but is not limited to: developing a care plan, encouraging behavior changes, identifying and addressing barriers, helping members to coordinate care, and identifying various resources to assist members in achieving their personal health goals. The incumbent monitors, improves and maintains quality outcomes (clinical, financial and functional) for the specified panel of members.
Maintain oversight over specified panel of members by performing ongoing assessment of members’ health management needs, identifying the right clinical interventions to address member needs and/or triaging members to appropriate resources for additional support.
For assigned case load, create care plans to address members’ identified needs, remove barriers to care, identify resources, and conduct a number of other activities to help improve the health outcomes of members; care plans include both long and short term goals and plan of regular contacts for re-assessment.
Ensure targeted percentage of patient goal achievement (i.e., realization of member care plan), and other patient outcomes, as applicable, are achieved.
Ensure all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards.
Maintain current knowledge and adheres to applicable CMS, state, local, and regulatory agency requirements and applicable standards of practice for case management including those published by CMSA and/or ACMA, as required by the organization.
Other duties as assigned or requested.
- High School Diploma/GED
- Bachelor's Degree in Nursing
- 7 years of any combination of clinical, case management and/or disease/condition management experience, provider operations and / or health insurance experience
Telephonic case management experience highly preferred.
Labor and Delivery and/or high-risk maternity/ NICU experience
Experience working with the healthcare needs of diverse populations
Understanding of the importance of cultural competency in addressing targeted populations
LICENSES AND CERTIFICATIONS
- RN license in PA, WV, and DE is required. At least one of these state licensures must be active at time of hire. Others must be obtained within the first 6months of employment. Additional state licensure may be required.
- Certification in Case Management
Written and verbal presentation skills, negotiation skills, and skills in positively influencing others with respect and compassion
Broad knowledge of disease processes
Understanding of healthcare costs and the broader healthcare service delivery system
Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate and act on clinical and financial data, including analysis of statistical data
Excellent interpersonal/ consensus building skills as well as the ability to work with a variety of internal and external colleagues from all levels of an organization
Ability to work in a high performing team environment that requires flexibility
Demonstrated ability to handle multiple priorities in a fast paced environment. Excellent organizational, time management and project management skills
Self-directed; self-starter, ability to work successfully with indirect supervision and moderate autonomy
LANGUAGE REQUIREMENT (Other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
Teaches/Trains others regularly
Travels regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (Sales employees)
Does Not Apply
Physical Work Site Required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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Req ID: J217658
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