RN Director of HROB Case Management - Managed Care
REMOTE - Work from Home
The role of the Director of High Risk OB Case Management is to develop leadership and staff in the pursuit of the highest quality case management for our most vulnerable members. Oversight of staff working with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated approach to assess for maternal care needs and high risk maternal care needs, including behavioral health/ substance use. HROB staff work to ensure that members follow milestone appointments and have coaching on self-management for risk areas to optimize birth outcomes.
The Director is responsible for being the “final authority” for Case Management staff. This includes questions regarding procedures, training, and processes to assure compliance with policies and procedures. Develops and implements effective and efficient standards, protocols and processes, reports and benchmarks that support and further enhances utilization management function and quality of healthcare services. Ensure provision of appropriate care through prospective, concurrent and retrospective reviews of services.
- Understand, promote and audit the principles of Case Management to facilitate the right care at the right time in the right setting.
- Identify trends or issues in the Case Management process that requires further evaluation for their quality or utilization implications and bring these items to the attention of the Utilization Management Director.
- Communicate effectively and interact with the medical directors, hospitalists, provider offices, staff and health plans daily or as indicated regarding Utilization Management and referral authorization issues. Possess excellent case management skills including but not limited to, development and monitoring of care plans, post discharge calls, Vital Care referrals, hospital contracts, stop loss and DRG.
- Take responsibility for under resourced issues and resolve workflow bottlenecks.
- Other duties as assigned.
- Requires a valid, unrestricted state Registered Nurse (RN) license
- Requires Bachelor’s Degree in Nursing (BSN) or related field. Master’s degree preferred.
- Certified in Case Management (CCM) or Utilization Management (CPUM/CPUR) preferred.
- 5+ years Case Management experience.
- 5+ years managerial experience and leadership of a Case Management staff in a managed care environment.
- Familiarity with Medicaid managed care practices and policies, CHIP, and SCHIP.
- Experience in training / teaching staffs to meet operational requirements and goals.
EXCELLENT BENEFITS AND HIGHLY COMPETITIVE SALARY OFFERED!
Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members. The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.