The Clinical Care Manager/Maternal Child Health completes clinical assessments on pregnant members who are at-risk for an adverse delivery to determine the educational health needs based on their pregnancy/disease process, and to monitor their level of adherence. Provides ongoing management of the mother and complex newborn functioning as a “Nurse in the Family”. Provides and promotes self-management support including care integration for members enrolled in the Sunny Start program. Leads the interdisciplinary team in the development and implementation of the care plan to enhance the members overall prenatal/postpartum health, and to achieve appropriate utilization. Assesses plans, implements, coordinates, monitors and evaluates care plans, services and outcomes to maximize the maternal/child health of members.
KEY FUNCTIONS/RESPONSIBILITIES:
- Completes a comprehensive assessment and develops a care plan utilizing clinical expertise to evaluate the member’s needs for alternative services. Assesses short-term and long-term needs and establishes condition management objectives
- Provides ongoing telephonic and in-person outreach to conduct ongoing focused assessments
- Educates and assists members in understanding their pregnancy/disease process in an effort to self-management and maximize optimal health
- Emphasizes the importance of pregnancy health education and teaches member behavior modification techniques
- Utilizes evidenced based guidelines to educate members on their pregnancy/specific disease processes
- Identifies member educational needs and ensures the mailing of appropriate educational material to each member and/or provides in-person educational materials to members
- Ensures coordination of prenatal and parenting programs, prenatal and postpartum physician appointments, and coordination of psychosocial and socioeconomic needs.
- Manages the needs of complex newborns, promoting safety and educating members about the importance of preventive and well visit appointments, immunizations, and other appointments falling under EPSDT services, coordinating transportation, as necessary
- Assess/monitors members clinical and behavior modification changes and document in CCMS
- Promotes and encourages members regarding adherence to their care plan as prescribed by and in collaboration with their treating physician
- Communicates/Collaborates with provider regarding member needs.
- Acts as a liaison and member advocate between the member and their family, physician, and facilities/agencies.
- Facilitates interdisciplinary teamwork to ensure coordination of care through participation in rounds, team meetings and clinical reviews in CCMS documents clinical assessments and coordinator of care in the medial management information system in a timely manner that meets regularity and accreditation standards as well as internal policy.
- Utilizes data to ensure that clinical interventions result in improved clinical outcomes and appropriate utilization of services at an appropriate cost.
- Assess options for care including use of benefits and community resources to update the care plan as needed.
- Communicates with Physicians, Hospitals, Ancillary providers and Community agencies as needed to communicate or receive essential clinical and or psychosocial information related to a members care.
- Maintains HIPPA standards and confidentiality of protected health information. Reports critical incidents and information regarding quality of care issues.
- Ensures compliance with all state and federal regulations in day to day activities
- Other duties as assigned.
SUPERVISION RECEIVED:
- Weekly and on-going from Manager of Care Management
QUALIFICATIONS:
EDUCATION REQUIRED:
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- Bachelors Degree in Nursing or Associate’s degree in Nursing and relevant work experience.
EXPERIENCE REQUIRED:
- 2 years of experience with case management, care coordination, and/or discharge planning
- 3 years of related experience working with people in maternal/child health, maternity or obstetrics in an acute care or health insurance environment
PREFERRED/DESIRABLE:
- 1-2 years experience in home health care
- Experience working with Medicaid recipients and community services
- Experience with FACETS, CCMS, or other healthcare database
CERTIFICATION OR CONDITIONS OF EMPLOYMENT:
- Current unrestricted, applicable, state license to practice as a Registered Nurse
- Pre-employment background check.
- CCM certification preferred
- Regular and reliable transportation and the ability to conduct face-to-face appointments with members, providers, community and state agencies
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COMPETENCIES, SKILLS, AND ATTRIBUTES:
- Strong Motivational Interviewing skills
- Strong oral and written communication skills
- Ability to effectively collaborate with health care providers and all members of the multidisciplinary team
- Strong technical skills and ability to document in the Plan’s care management documentation system in real-time when meeting with members and providers in-person or by phone.
- Demonstrated organizational and time management skills
- Able to work in a fast paced environment and multi task
- Experience with Microsoft Office application, particularly MS Outlook and MS Word and other data entry processing applications
- Strong analytical and clinical problem solving skills
WORKING CONDITIONS AND PHYSICAL EFFORT:
- Regular and reliable attendance is an essential function of the position.
- Work may be performed in a typical interior/office work environment or in a home office except when conducting face-to-face visits.
- Face-to-face visits may be conducted in a member’s home, shelters, physician practices, hospitals, or at a mutually agreed upon location between the member and the care manager and also with community and state agencies, as appropriate.
- No or very limited physical effort required. No or very limited exposure to physical risk.
- Fast paced office environment
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.
Required Skills
Required Experience