Prenatal Care Manager (DC Medicaid) at CareFirst BlueCross BlueShield in Washington, Washington DC

Job Description:

Resp & Qualifications

PURPOSE:

The Prenatal Care Manager provides obstetrical assessment and case management for high risk pregnant enrollees to improve the health outcomes of pregnant women. Will provide the full continuum of services from coordination of care to disease management for all high risk and complex pregnant cases. Activities include assessment, care plan development and implementation, coordination of services, monitoring and evaluation throughout pregnancy. Additional responsibilities include health education, data tracking and reporting, referral management, healthy pregnancy initiative program management, treatment decision support, and documentation of findings and services.

PRINCIPAL ACCOUNTABILITIES:

Under the general direction of the Director and Manager of Case Management, the Care Manager s accountabilities include, but are not limited to, the following (specific goals for Case Management Department are determined on an annual basis in accordance with directives from the executive board of CareFirst Community Health Plan Blue Cross Blue Shield):

1. CASE MANAGEMENT PROCESS
2. Identification/Risk Stratification:) Engages enrollees into the case management program (outreach and successful enrollment) using appropriate risk algorithms and predictive analytics tools.
3. Assessment: Conducts and documents a comprehensive assessment of the enrollee s health psychosocial needs, including health literacy and deficits. Obtains verbal consent to initiate case management services. Gathers clinical data, which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include available support systems, available benefits, community resources, and treatment and medication compliance according to NCQA Case Management Accreditation standards.
4. Planning: Proficient case management clinical knowledge and experience to coordinate integrated care-plan development involving the enrollee, family, Hospital Transition of Care (HTC) nurse, Care Coordination (CC) and Care Manager (RNCM), Primary Care Physician (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition and meet NCQA standards of documentation for Case Management Accreditation
5. Facilitation of Communication and Care Coordination: One key responsibility of the case manager is to minimize the fragmentation of care services and adverse outcomes. Case management will assist enrollees with any transition of care. Provides educational and community resources, support groups, pharmacy program and financial assistance.

* Monitoring: Documentation will reflect the necessary communication with the enrollee, family, physicians, and other health care providers to ensure the enrollee s progression in meeting the established care plan goals.
* Outcomes Management: Evaluate the extent to which the established goals in the plan of care have been achieved.

1. APPLICATION PROFICIENCY
2. Portal Data Base: Case management documentation is completed in the Care Connect system
3. Claims: Assists in claims inquiries and resolution
4. Legacy Systems (MHC and Care Connect: Confirms enrollee eligibility and available benefits)
5. Care Planner Web: Authorization management; generates coverage and adverse decision correspondence using appropriate language to meet state, federal and all regulatory requirements
6. Employer Group/Accreditation Audits: Participates in the preparation and on-site reviews (NCQA, OSR and DHCF)
7. Knowledgeable of federal/state mandates as they apply to various plan contracts
8. Documentation Audit: Responsible for completion of documentation review and peer to peer audit as assigned by management
9. MCG Chronic Care Guidelines: Familiarity with and usage of for the purpose of discharge planning (and length of stay review for FEP Line of Business only)
10. NCQA Compliance: Responsible for adherence to the NCQA Complex Case Management Standards and Health Plan Standards
11. CMSA: Adheres to the CMSA Standards of Practice for Case Management
12. HIPAA: Maintains confidentiality of patient information according to HIPAA and departmental policies.

1. OTHER DUTIES AS ASSIGNED
2. Presents cases to medical management rounds once a quarter at a minimum
3. Compiles success story/case review for medical management department use

QUALIFICATION REQUIREMENTS:

To perform the job successfully, an individual should demonstrate the following competencies:

* Analytical - Experience working with statistical methodologies, analytical and statistical theories. Knowledge of applied use of data in health program monitoring and evaluation.
* Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations.
* Project Management - Communicates changes and progress; Completes projects on time and budget.
* Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.
* Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
* Interpersonal Skills - Solution oriented approach to conflict and challenges; Maintains confidentiality; Practices effective listening skills; Maintains professional demeanor; Remains open to others' ideas and tries new things.
* Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Actively participates in meetings.
* Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Able to read and interpret written information.
* Quality Management - Demonstrates accuracy and thoroughness. Applies quality assurance principles to data management activities.
* Diversity - Shows respect and sensitivity for cultural differences; Promotes a harassment-free environment and respects diversity.
* Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
* Organizational Support - Understands organization's goals and values and role in achieving those goals; Follows policies and procedures; Completes administrative tasks correctly and on time.
* Strategic Thinking - Develops strategies to achieve organizational goals; Understands organization's strengths & weaknesses; Analyzes market and competition; Adapts strategy to changing conditions.
* Judgment - Displays willingness to make decisions; Includes appropriate people in decision-making process; makes timely and data-driven decisions.
* Motivation - Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles.
* Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Ability to multi-task.
* Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
* Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
* Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions.
* Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the sit