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RN Maternity Case Mgr
41830 WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. What is your impact? The RN Maternity Case Manager will be a member of our Case Management department and will work within the Maternity Management program, which assists in managing healthcare costs for expectant mothers. The RN Maternity Manager (MM) focuses on wellness/wellbeing and education of expectant mothers, as well as traditional case management practices as it relates to mothers-to-be with high-risk pregnancies. What Will You Be Doing:
- Maternity Case Management process includes assessing the member’s health status and care coordination needs. Can include inpatient discharge planning, as well as possible outpatient management.
- Contact with patient, family, physicians, additional health care providers, and community resources. Contact with provider business offices and with the employer/client may also be required.
- Identification of alternative treatment plans, which would have to be approved by all parties. These alternative care plans will be based on quality care within cost containment guidelines, allowing available claims dollars to be used in the most judicious manner possible.
- Monitor the health status and the impact of the treatment plan for each member. The Maternity Manager will be responsible for altering the care plan as deemed appropriate by the dynamic, ever-changing member needs.
- Identification of services, resources, providers, and facilities that could best serve members in a timely and cost-effective manner, to promote optimum value for the member and reimbursement source.
- Development and implementation of Case Management goals, both short and long term, with documented care plans.
- Utilize technology/resources to evaluate the cost-effectiveness of the elected treatment plan, pre-implementation and post-implementation. This outcome measurement will be used in determining the effective results and in establishing future patient-centered care plans.
- Accurate and timely reporting as deemed appropriate by each client.
- Interpreting individual health plans and authorizing/coordinating care in accordance with plan provisions.
- 5+ years professional work experience in clinical nursing and patient assessment.
- Related Bachelor’s degree or additional related equivalent work experience
- Graduate of an accredited school of nursing
- RN - Registered Nurse - State Licensure in good standing.
- RN Compact State Licensure
- (CCM) Certified Case Manager preferred
- Prior experience with maternal health, prenatal care, and/or high-risk pregnancy management in a clinical setting.
- Prior experience in utilization management or case management preferred, preferably within the managed care environment
- Knowledgeable in medical terminology, reasonable and necessary treatment plans, delivery quality health care services and cost containment practices.
- Ability to collaborate with cross-operational areas within the organization.
- Intensive care or higher-acuity patient experience preferred.
- Knowledge of managed care in a self-funded employer population is preferred.
- Ability to identify problems such as underutilization or overutilization of services
- Ability to promote and maintain quality care through analysis
