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Position Description

Arkansas Blue Cross and Blue Shield - EXEMPT POSITION DESCRIPTION

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Position:  Case Mgr/Life w/baby
Reports To: 
Division:  WalMart Medical Affairs (2111)
Company:  ABCBS
Location:  Label
Job Code:  030309
Min Salary:   56800
Date:  10/13/2009

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Position Specific Requirements: None


Job Summary
This position is responsible for the identification of high cost/high risk obstetric and neonatal patients, the assessment of alternative treatment methods and the management of health care benefits for these patients as cost effectively as possible.  The incumbent must work closely with the physician, patient, family and home care agencies.  This position is active in assisting in the management of the health care benefits of the member, and decisions must be executed in a professional manner.

Nature & Scope
*Environment

This position works with the Life with Baby Staff.  The organizational environment of the job is one of independent decision-making in a cooperative relationship with physicians, members/policyholders, families/caregivers, employer group contacts, home health agencies, hospital and Enterprise case managers and others involved in the coordination of alternative care for patients.

*Workflow

The incumbent’s primary workload is established through contacts with high risk obstetric patients identifies by the Life with Baby program screening tool, and form referrals by physicians, home care agencies or employer groups.  The Case Manager will be responsible to identify appropriate candidates for case management and activate cases in the most cost effective method available that maintains the quality of care received by the patient.  This position will be responsible for maintaining contact with the high risk obstetric patient during her pregnancy and obtaining delivery outcome information for all participants in the Life with Baby program.  The role will also include follow-up of the infant after delivery for the assessment of possible case management needs.

Work assignments directly or indirectly will be received from the Life with Baby Supervisor.  Work assignments may be self-imposed resulting from problem resolution activities.  The incumbent is directly involved in the work to be accomplished, including the planning, design and activation phases of any new project involving the Life with Baby program.

Responsibilities may also include review of medical records at the various hospitals for Arkansas Blue Cross Blue Shield and Blue Advantage Administrators of Arkansas (BAAA) currently hospitalized to identify high risk/cost obstetric and/or neonatal patients that could be managed in an alternative setting.

*Guidance

In the accomplishment of the established workload, the incumbent receives guidance from the Walmart Medical Affairs Manager and the Life with Baby Supervisor.  This guidance includes clinical advice, defined objectives and goals to be met.  In addition, the case manager is guided by Company Policies and Procedures and Case Management Procedures in order to maintain consistency in decision making and case management applications.
*Challenges

The ongoing challenges of this position are to meet department deadlines for implementation of case management reporting mechanisms, utilize case management software in several systems to maintain accurate patient records and assist providers in coordination of alternative care with quality providers.

*Interfaces

The incumbent’s primary contacts within the company are as follows: All Departments (including Vice Presidents, Managers, and Supervisors) to meet their needs and resolve problems.  The incumbent’s principal contacts outside the company are as follows: the incumbent must communicate effectively with physicians, home health agency personnel, members/policyholders, families/caregivers, hospital personnel, employer group contacts, Case Managers and all others as needed to fulfill case management responsibilities.

*Authority

The incumbent has the authority to implement case management for an obstetrical and neonatal patient who meets guidelines for care.  When complexities of these situations or resolution of problems exceed the incumbent’s scope of knowledge and experience, they are referred to the Life with Baby Supervisor or Walmart Medical Management for settlement.  The incumbent must communicate effectively with physicians, patients, families/caregivers, group administrators and home health care agencies.

This position works closely with Walmart Medical Management, the Regional Medical Affairs Managers and Case Managers and the Corporate Medical Director, and serves as a key implementer of medical management programs.

Minimum Job Requirements
 Minimum Job Requirements
  • 1. A registered nurse licensed and in good standing in the State of Arkansas with clinical practice experience with two of those years being in obstetrics or neonatal care.
  • 2. Obstetric and neonatal care clinical practice experience must be recent (within last year).
  • 3. College degree in health related field desired (preferably nursing, social work, or psychology).
  • 4. CCM required or eligible to sit for exam within two years of employment.

 

Written materials produced by this role include: procedures, case management and cost savings reports, correspondence to patients and physicians; and interoffice communications.  The incumbent will assist the Life with Baby Supervisor in the production of proposals for new projects.

A significant part of the Case Manager's role is the efficient scheduling, planning and coordination of responsibilities to accomplish goals and objectives set by the individual, Medical Affairs department and the corporation.


Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
ACTIVITY END RESULT
1. Assist with risk assessment data collection and identifying potential case, maintain monthly (more frequently, if needed), management needs, high risk obstetric follow-up.
2. Identify appropriate alternate care settings for maintaining case managed patient, quality care and cost containment, coordination of load, home health care, and other alternative delivery services.

ACTIVITY
3. Maintain close contact with case managed patients with weekly telephone follow-up as needed to evaluate quality and medical necessity of care.
4. Maintain accurate documentation of case management activities, including collection of data for continuous quality improvement.
5. Conduct ongoing communication with the Life with Baby Supervisor, regional case managers, Walmart Medical Affairs Manager and the Medical Director regarding ongoing clinical issues, delivery system issues and other program issues within the line of business.
6. Collect data for reporting: types of cases registered (high verses high risk), number precerted versus number of regular outcomes including term verses preterm.
7. Ongoing telephone follow-up with home health agencies to evaluate quality and medical necessity of care.
8. Review referrals for appropriateness.

END RESULT

Identifying potential problems with member education, related to quality issues of home health

Assisting with continuous improvement of Life with Baby and case management

Maintaining interoffice communications and marketing efforts

Enhance awareness of program

Demonstrates overall success of the program and identifies areas of concern

Indentify potential problems and /or change in needs

Promotes follow-up on patients with current needs
*******    END    *******
 


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