This position is responsible for the identification of high cost/high risk obstetric and neonatal patients, the assessment of alternative treatment methods and the management of health care benefits for these patients as cost effectively as possible. The incumbent must work closely with the physician, patient, family and home care agencies. This position is active in assisting in the management of the health care benefits of the member, and decisions must be executed in a professional manner.
Nature & Scope
This position works with the Life with Baby Staff. The organizational environment of the job is one of independent decision-making in a cooperative relationship with physicians, members/policyholders, families/caregivers, employer group contacts, home health agencies, hospital and Enterprise case managers and others involved in the coordination of alternative care for patients.
The incumbent’s primary workload is established through contacts with high risk obstetric patients identifies by the Life with Baby program screening tool, and form referrals by physicians, home care agencies or employer groups. The Case Manager will be responsible to identify appropriate candidates for case management and activate cases in the most cost effective method available that maintains the quality of care received by the patient. This position will be responsible for maintaining contact with the high risk obstetric patient during her pregnancy and obtaining delivery outcome information for all participants in the Life with Baby program. The role will also include follow-up of the infant after delivery for the assessment of possible case management needs.
Work assignments directly or indirectly will be received from the Life with Baby Supervisor. Work assignments may be self-imposed resulting from problem resolution activities. The incumbent is directly involved in the work to be accomplished, including the planning, design and activation phases of any new project involving the Life with Baby program.
Responsibilities may also include review of medical records at the various hospitals for Arkansas Blue Cross Blue Shield and Blue Advantage Administrators of Arkansas (BAAA) currently hospitalized to identify high risk/cost obstetric and/or neonatal patients that could be managed in an alternative setting.
In the accomplishment of the established workload, the incumbent receives guidance from the Walmart Medical Affairs Manager and the Life with Baby Supervisor. This guidance includes clinical advice, defined objectives and goals to be met. In addition, the case manager is guided by Company Policies and Procedures and Case Management Procedures in order to maintain consistency in decision making and case management applications.
The ongoing challenges of this position are to meet department deadlines for implementation of case management reporting mechanisms, utilize case management software in several systems to maintain accurate patient records and assist providers in coordination of alternative care with quality providers.
The incumbent’s primary contacts within the company are as follows: All Departments (including Vice Presidents, Managers, and Supervisors) to meet their needs and resolve problems. The incumbent’s principal contacts outside the company are as follows: the incumbent must communicate effectively with physicians, home health agency personnel, members/policyholders, families/caregivers, hospital personnel, employer group contacts, Case Managers and all others as needed to fulfill case management responsibilities.
The incumbent has the authority to implement case management for an obstetrical and neonatal patient who meets guidelines for care. When complexities of these situations or resolution of problems exceed the incumbent’s scope of knowledge and experience, they are referred to the Life with Baby Supervisor or Walmart Medical Management for settlement. The incumbent must communicate effectively with physicians, patients, families/caregivers, group administrators and home health care agencies.
This position works closely with Walmart Medical Management, the Regional Medical Affairs Managers and Case Managers and the Corporate Medical Director, and serves as a key implementer of medical management programs.
Minimum Job Requirements
Minimum Job Requirements
- 1. A registered nurse licensed and in good standing in the State of Arkansas with clinical practice experience with two of those years being in obstetrics or neonatal care.
- 2. Obstetric and neonatal care clinical practice experience must be recent (within last year).
- 3. College degree in health related field desired (preferably nursing, social work, or psychology).
- 4. CCM required or eligible to sit for exam within two years of employment.
Written materials produced by this role include: procedures, case management and cost savings reports, correspondence to patients and physicians; and interoffice communications. The incumbent will assist the Life with Baby Supervisor in the production of proposals for new projects.
A significant part of the Case Manager's role is the efficient scheduling, planning and coordination of responsibilities to accomplish goals and objectives set by the individual, Medical Affairs department and the corporation.
This position is identified as level three (3). This position must ensure the security
and confidentiality of records and information to prevent substantial harm, embarrassment,
inconvenience, or unfairness to any individual on whom information is maintained.
The integrity of information must be maintained as outlined in the company Administrative
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented
or detected on a timely basis by employees in the normal course of business. This
position must adhere to the segregation of duties guidelines in the Administrative
Arkansas Blue Cross and Blue Shield - 13 months ago