Maternity Case Manager RN(Remote) - Nashville, United States - Lucent Health Solutions LLC

Description

Job Description

JOB DESCRIPTION

Case Manager– Maternity, RN
Remote

Role Summary

The maternity case manager shall work in a collaborative means to promote quality care and cost- effective outcomes that will enhance the physical, psychosocial, and vocational health of the plan participants. The case manager shall work within the policies and procedures of Lucent Health and according to the Practice Guidelines accepted by the profession of case management.

Responsibilities

Performs all phases of the case management process which shall include:

Assessment

• Defines role and scope of activities to the patient in a comprehensible manner.
• Communicates to the patient that the information gathered will be shared with the payer.
• Gathers consent for case management activities.
• Determines individual needs based on an assessment that identifies all significant needs related to the Medical condition and care (current diagnosis - primary and secondary, treatment plan and prognosis, projected length of treatment/anticipated cost, physicians - primary and specialists, significant history - patient and family, response to previous treatment, potential problems and complications, patient understanding of diagnosis and prognosis, experimental/controversial treatment, anticipated location of care, medications, need for equipment/supplies/etc., need for ancillary services), the Psychosocial condition and care (language, cultural influences, support systems and significant others, financial status, coping behaviors, compliance issues, living arrangements, home environment, religious beliefs, advance directives, patient goals/plans/wishes, teaching needs, transportation issues, ability to perform self-care), the Vocational situation (current vocational status, training/education, desire to return to work, job description, transferable skills, general interests/talents, wage earning abilities), the Payer issues (benefit plan design, PPO'S, policy limits/exclusions, eligibility for additional resources, ability to go outside of policy limits, laws affecting coverage, payer contact), available community resources, and barriers to effective outcomes.
• Works in a holistic manner, considering both medical and psychosocial issues.
• Identifies issues that might interfere with the provision of the highest quality, most appropriate, cost-effective care.
• Keeps in mind that a thorough, objective assessment is necessary to a successful outcome.

Planning and Coordination:

• Creates an individualized plan of action based on the assessment which facilitates the coordination of appropriate and necessary treatment and services required by the patient.
• Gives consideration, in developing the plan, to the benefit plan design/coverage options. Sets appropriate, measurable goals.
• Provides the patient with information to make "informed" decisions, empowering and encouraging the patient to make his own decisions through including him in the planning process.
• Develops contingency plans
• Facilitates communication of the patient's wishes to all members of the health care team.
• When appropriate, discusses advanced directives.
• Obtains the acceptance of all parties (patient, family, payer, and providers) prior to instituting the plan.
• Develops a plan which advocates for the patient and maximizes benefit dollars.
• Researches and includes costs of services and use of community resources in plan design.

Implementation and Monitoring:

• Implements a plan that is based on the assessment. Skillfully negotiates and coordinates care based on the plan developed.
• Identifies and coordinates resources to ensure success of the plan.
• Works within the plan network as possible. Refers to only those providers that are familiar or researched to ensure high quality (either through personal knowledge/experience, onsite inspections, conversations with providers, review of accreditations and credentials, networking with other case managers, review of outcomes, statistics, payer, and patient satisfaction).
• Monitors the provision of the coordinated plan.
• Reviews the care plan for compliance with standards of care and coordinates physician review when needed of procedures, medications, and care plans to ensure that services are medically necessary and consistent with care standards and health plan language.
• Appropriately communicates the outcome of medical necessity reviews per policy.

Evaluation

• Evaluates plan on a regular basis to determine effectiveness, patient satisfaction, provider comfort, payer satisfaction, if the plan is meeting the needs of all involved parties (but most particularly-the patient's needs) cost effectiveness, patient compliance with treatment, and the impact on the patient's quality of life.
• Determines if revisions are required due to changes in medical condition, family status, insurance coverage, etc.
• Maintains availability and willingness to revise the plan as needed.
• Continues involvement as active, effective case manager.

Other Skills

• Maintains well-organized, objective, factual, clear, and concise documentation that reflects what was done on the cases and why it was done, adhering to policies regarding timeliness. Documentation of the plan must include who, what, where, when why and costs. Teaching of the patient and family is documented.
• Performs as a patient advocate, in an ethical manner at all times, incorporating case management concepts and following industry standards and guidelines.
• Becomes involved in the case management process as early as possible following the onset or diagnosis and maintains involvement throughout the course of the illness or injury (not just episodically), managing a case along the entire spectrum of care (home care, acute care hospital, subacute, rehabilitation, etc.), coordinating cost effective plans that provide quality and continuity of care while eliminating duplication of services and wasted benefit dollars.
• Demonstrates effective communication skills, both written and verbal, with all members of the treatment (physicians, providers, patients, families, significant others), employer, and payer team.
• Adheres to the Quality Assurance standards of the unit at a minimum of 85% of the time.

Education and Experience Required

1. Active, unrestricted RN license in the state(s) of practice - Multi State license required.

2. Current certified case manager (CCM) credential preferred.

3. A minimum of three (3) years of clinical experience in maternity telephonic case management, facility case management or nurse navigator experience. Preferred clinical experience in bedside maternity nursing environment.

4. Ability to multi-task including navigation of multiple systems, multiple monitors, and have a conversation via telephone simultaneously.

5. Excellent time management and organizational skills, with the ability to maintain flexibility and work independently.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Equal Employment Opportunity Policy Statement

Lucent Health Solutions, Inc. is an Equal Opportunity Employer.