RN Case Management Coordinator - NICU/Maternity (W@H SC)

About the role

The RN Case Management Coordinator role focuses on improving care coordination and reducing fragmentation in care, aiming to enhance client safety, well-being, and quality of life. Care management interventions are designed to align with the "Triple Aim" objectives: improving health outcomes, enhancing the experience of care, and reducing healthcare costs.

Responsibilities

• Provides active care management, assesses service needs, develops and coordinates action plans, monitors services, and implements plans, including member goals.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Provides telephonic support for members with chronic conditions, high-risk pregnancies, or other at-risk conditions, conducting intensive assessments, providing educational materials, and using motivational interviewing techniques to facilitate behavior change.
• Participates in direct intervention and patient education with members and providers regarding the health care delivery system, utilization on networks, and benefit plans.
• May identify, initiate, and participate in on-site reviews. Serves as a member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs. Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
• Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff.
• Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies.
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.

Requirements

The candidate must have an Associates degree in a job-related field or equivalent 2 years of recent clinical experience in defined specialties such as oncology, cardiology, neonatology, maternity, rehabilitation services, mental health/chemical dependency, orthopedic, general medicine/surgery. Alternatively, 4 years of utilization review/case management/clinical experience, with 2 of those years being clinical.

Knowledge of quality improvement processes and demonstrated ability with these activities. Knowledge of contract language and application. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.

Preferred Work Experience

4 years of NICU and/or Maternity experience. Prior experience in lactation consulting is highly preferred.

Preferred Skills and Abilities

Working knowledge of spreadsheet, database software. Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. Case Manager certification, clinical certification in specialty area.

Benefits

We offer a comprehensive benefits package including subsidized health plans, dental and vision coverage, a 401(k) retirement savings plan with company match, life insurance, paid time off (PTO), on-site cafeterias and fitness centers, and more. We also provide reasonable accommodations for individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs.