CareFirst Careers

Care Manager, Postpartum (DC Medicaid)

Resp & Qualifications

PURPOSE:

The Postpartum Care Manager provides obstetrical assessment and case management for high risk postpartum enrollees and their newborns to improve the health outcomes of pregnant women and their babies. Will provide the full continuum of services from coordination of care to disease management for all high risk and complex postpartum cases. Activities include assessment, care plan development and implementation, coordination of services, monitoring and evaluation through 84 days post delivery and for the first year of life of the newborn. Additional responsibilities include health education, data tracking and reporting, referral management, healthy pregnancy initiative program management, treatment decision support, and documentation of findings and services.

PRINCIPAL ACCOUNTABILITIES: 

Under the general direction of the Director and Supervisor of Case Management, the Care Manager’s accountabilities include, but are not limited to, the following (specific goals for Case Management Department are determined on an annual basis in accordance with directives from the executive leadership of CareFirst Community Health Plan Blue Cross Blue Shield):

 

  1. CASE MANAGEMENT PROCESS
  • Identification/Risk Stratification:) Engages enrollees into the case management program (outreach and successful enrollment) using appropriate risk algorithms and predictive analytics tools.
  • Assessment: Conducts and documents a comprehensive assessment of the enrollee’s health psychosocial needs, including health literacy and deficits.  Obtains verbal consent to initiate case management services. Gathers clinical data, which includes past medical history, medications, physical/psychosocial factors, cultural influences, evaluation of health care barriers to include available support systems, available benefits, community resources, and treatment and medication compliance according to NCQA Case Management Accreditation standards.
  • Planning: Proficient case management clinical knowledge and experience to coordinate integrated care-plan development involving the enrollee, family, Hospital Transition of Care (HTC) nurse, Care Coordination (CC) and Care Manager (RNCM), Primary Care Physician (PCP), specialists and other healthcare providers/vendors. Goals developed will be prioritized, action-oriented and time-specific to stabilize the complicated health care condition and meet NCQA standards of documentation for Case Management Accreditation
  • Facilitation of Communication and Care Coordination: One key responsibility of the case manager is to minimize the fragmentation of care services and adverse outcomes. Case management will assist enrollees with any transition of care.  Provides educational and community resources, support groups, pharmacy program and financial assistance.
    • Monitoring: Documentation will reflect the necessary communication with the enrollee, family, physicians, and other health care providers to ensure the enrollee’s progression in meeting the established care plan goals.
    • Outcomes Management: Evaluate the extent to which the established goals in the plan of care have been achieved.

 

  1. APPLICATION PROFICIENCY
  • Portal Data Base: Case management documentation is completed in the Care Connect system
  • Claims: Assists in claims inquiries and resolution
  • Legacy Systems (MHC and Care Connect: Confirms enrollee eligibility and available benefits)
  • Care Planner Web:  Authorization management; generates coverage and adverse decision correspondence using appropriate language to meet state, federal and all regulatory requirements
  • Employer Group/Accreditation Audits: Participates in the preparation and on-site reviews (NCQA, OSR and DHCF)
  • Knowledgeable of federal/state mandates as they apply to various plan contracts
  • Documentation Audit: Responsible for completion of documentation review and peer to peer audit as assigned by management
  • MCG Chronic Care Guidelines:  Familiarity with and usage of for the purpose of discharge planning (and length of stay review for FEP Line of Business only)
  • NCQA Compliance: Responsible for adherence to the NCQA Complex Case Management Standards and Health Plan Standards
  • CMSA: Adheres to the CMSA Standards of Practice for Case Management
  • HIPAA: Maintains confidentiality of patient information according to HIPAA and departmental policies.

 

  1. OTHER DUTIES AS ASSIGNED
  • Presents cases to medical management rounds once a quarter at a minimum
  • Compiles success story/case review for medical management department use

 

QUALIFICATION REQUIREMENTS:

To perform the job successfully, an individual should demonstrate the following competencies:

  • Analytical - Experience working with statistical methodologies, analytical and statistical theories. Knowledge of applied use of data in health program monitoring and evaluation.
  • Problem Solving - Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations.
  • Project Management - Communicates changes and progress; Completes projects on time and budget.
  • Technical Skills - Assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others.
  • Customer Service - Manages difficult or emotional customer situations; Responds promptly to customer needs; Solicits customer feedback to improve service; Responds to requests for service and assistance; Meets commitments.
  • Interpersonal Skills - Solution oriented approach to conflict and challenges; Maintains confidentiality; Practices effective listening skills; Maintains professional demeanor; Remains open to others' ideas and tries new things.
  • Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Actively participates in meetings.
  • Written Communication - Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Able to read and interpret written information.
  • Quality Management - Demonstrates accuracy and thoroughness. Applies quality assurance principles to data management activities.
  • Diversity - Shows respect and sensitivity for cultural differences; Promotes a harassment-free environment and respects diversity.
  • Ethics - Treats people with respect; Keeps commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
  • Organizational Support - Understands organization's goals and values and role in achieving those goals; Follows policies and procedures; Completes administrative tasks correctly and on time.
  • Strategic Thinking - Develops strategies to achieve organizational goals; Understands organization's strengths & weaknesses; Analyzes market and competition; Adapts strategy to changing conditions.
  • Judgment - Displays willingness to make decisions; Includes appropriate people in decision-making process; makes timely and data-driven decisions.
  • Motivation - Sets and achieves challenging goals; Demonstrates persistence and overcomes obstacles.
  • Planning/Organizing - Prioritizes and plans work activities; Uses time efficiently; Plans for additional resources; Ability to multi-task.
  • Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
  • Quality - Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
  • Safety and Security - Observes safety and security procedures; Reports potentially unsafe conditions.
  • Adaptability - Adapts to changes in the work environment; Manages competing demands; Changes approach or method to best fit the situation; Able pivot work with frequent change, delays, or unexpected events.
  • Attendance/Punctuality - Consistently at work and on time; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.
  • Dependability - Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan.
  • Initiative - Volunteers readily; Undertakes self-development activities; Seeks increased responsibilities; Looks for and takes advantage of opportunities; Asks for and offers help when needed.

 

OTHER SKILLS

LANGUAGE SKILLS   | Ability to read, analyze, and interpret health and science periodicals, professional journals, technical procedures, or governmental regulations.  Ability to write reports, business correspondence, and procedure manuals.  Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the public.

 

MATHEMATICAL SKILLS   | Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Knowledgeable of advanced statistical methodology.

 

REASONING ABILITY | Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

 

COMPUTER SKILL | To perform this job successfully,  an individual should have advance knowledge and proficiency in statistical data processing and visualization software such as Tableau, Spreadsheet software, and SAS, as well as Microsoft Office, Word Processing software, and SharePoint.

 

PHYSICAL DEMANDS | The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

WORK ENVIRONMENT | The noise level in the work environment is usually minimal to moderate. The work environment is fast paced with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

 

 

 

Required Education/Experience/Skills/Abilities:

  • Registered Nurse License in the District of Columbia in good standing
  • Associate’s Degree in Nursing
  • Certified Case Management Certification must be obtained within 2 years from hire date
  • Three to Five Years of experience in case management (community, homecare, hospice, or managed care)

Preferred:

  • Bachelor’s Degree in Nursing Preferred
  • Certified Case Management Certification preferred

 

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


PHYSICAL DEMANDS:

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is frequently required to reach with hands and arms. The employee is occasionally required to stand; walk; climb or balance; stoop, kneel or crouch.

The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds.

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

 

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 8.22.2020

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

Learn more about Medical Management