Women & Children's Outcomes Specialist II

CareSource•Mobile, AL

About The Position

Women & Children’s Health Outcomes Specialist II is responsible to execute quality monitoring reviews as defined by provider agreement to ensure at-risk pregnant members receive enhanced maternal care as outlined by the Ohio Department of Medicaid to drive improved birth outcomes. Essential Functions: Complete and submit requested reports to Ohio Department of Medicaid Identify members and/or providers claims analysis and enhanced maternal file to refer to High Risk OB care management program and follow up with provider Receive and input pregnancy risk assessment screenings into Nurture 2.0 and Guiding Care Review, identify and analyze Pregnancy Risk Assessments for completion, accuracy and trends to drive strategies to improve health outcomes for high risk pregnant members, including partnering with community and health partners. Facilitate coordination of member care as initial point-of-contact for pregnant members, ensuring primary care physicians, OB providers, community agencies, transportation, and other partners to ensure member barriers to care are minimized Collaboration with Women & Children’s Health Manager and/or High-Risk OB team identify populations within CareSource membership that would benefit from focused High Risk OB care coordination Collaborate with the Quality and CM teams to develop and implement projects related to improving health outcomes for the membership Knowledgeable in the prospective, retrospective, and concurrent review process of inpatient admissions, outpatient procedures, homecare services and durable medical equipment Verify eligibility, enrollment history, demographic data, and current health status of members Contribute to assessments by gathering information from the member, family, provider, and other stakeholders Identify provider coding opportunities to optimize both traditional and value-based reimbursement, reduce claims denials and integrate CareSource business partners in outreach efforts to increase provider satisfaction and drive improvement in HEDIS administration rates Outreach to members and/or providers to ensure effective administration of the program Perform any other job duties as requested

Requirements

Bachelor’s Degree in health care related field preferred and/or Associates Degree with equivalent experience.
Minimum of five (5) years maternal child/pediatric/discharge planning experience is required
Minimum of three (3) years utilization review and/or case management experience is preferred
Ability to manage and meet workloads and deadlines
Able to provide timely feedback to CareSource team members and business partners and prioritize provider and member engagement initiatives
Intermediate proficiency level with Microsoft Office, Outlook, Word, and Excel
Ability to communicate effectively with diverse population
Ability to multi-task and work independently within a team environment
Ability to collaborate with other internal team members to optimize birth and health outcomes for pregnant members
Knowledge of community and state support and advocacy resources for population served
Familiarity of state and federal healthcare regulations and environment
Critical listening and thinking skills and willingness to be flexible
Decision making and problem-solving skills
Proper grammar use and phone etiquette
Strong organizational and time management skills
Ability to work within autonomous role, adapting and modifying plan of care of member as required
Employment in this position is conditional pending successful clearance of a driver’s license record check.
To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position.
CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 – March 31) as a condition of continued employment.
Employees hired during Influenza season will have thirty (30) days from their hire date to complete the required vaccination and have record of immunization verified.
CareSource adheres to all federal, state, and local regulations.
CareSource provides reasonable accommodations to qualified individuals with disabilities or medical conditions, sincerely held religious beliefs, or as required by state law to enable the employee to perform the essential functions of the position.

Nice To Haves

Medicare/Medicaid experience preferred

Responsibilities

Complete and submit requested reports to Ohio Department of Medicaid
Identify members and/or providers claims analysis and enhanced maternal file to refer to High Risk OB care management program and follow up with provider
Receive and input pregnancy risk assessment screenings into Nurture 2.0 and Guiding Care
Review, identify and analyze Pregnancy Risk Assessments for completion, accuracy and trends to drive strategies to improve health outcomes for high risk pregnant members, including partnering with community and health partners.
Facilitate coordination of member care as initial point-of-contact for pregnant members, ensuring primary care physicians, OB providers, community agencies, transportation, and other partners to ensure member barriers to care are minimized
Collaboration with Women & Children’s Health Manager and/or High-Risk OB team identify populations within CareSource membership that would benefit from focused High Risk OB care coordination
Collaborate with the Quality and CM teams to develop and implement projects related to improving health outcomes for the membership
Knowledgeable in the prospective, retrospective, and concurrent review process of inpatient admissions, outpatient procedures, homecare services and durable medical equipment
Verify eligibility, enrollment history, demographic data, and current health status of members
Contribute to assessments by gathering information from the member, family, provider, and other stakeholders
Identify provider coding opportunities to optimize both traditional and value-based reimbursement, reduce claims denials and integrate CareSource business partners in outreach efforts to increase provider satisfaction and drive improvement in HEDIS administration rates
Outreach to members and/or providers to ensure effective administration of the program
Perform any other job duties as requested