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Position Title: Review Nurse – Women & Children's Services
Position Requirements: Full-Time Position
This position reports to the Manager of Women & Children's Services and is responsible for identification and coordination of care for pregnant women and newborns, including prenatal, postpartum, well baby care. This includes entering authorizations into the system and scheduling necessary appointments for members. Provides direct outreach to members and providers for education and coordination of care. Ensures tracking and reporting of key performance measures and collects data for HEDIS reporting.
Responsibilities to include:
- Assists with maintaining the women's program for prenatal, postpartum, MIHP, and preventive measures including but not limited to:
- Identifying pregnant members through Member Services referrals, the pregnant enrollee database, authorizations or claims.
- Authorizing services and scheduling their visits, coordinating their care and assisting with emergent/urgent requests.
- Managing pregnant members under the supervision of case management.
- Scheduling and authorizing postpartum visits.
- Assist with the scheduling and authorizing of preventive services for members.
- Tracking monthly numbers of new pregnancies, physician access problems, completed prenatal and postpartum visits, and preventive measures.
- Reporting monthly data on prenatal, postpartum and preventive measures.
- Monitoring the HEDIS databases for Prenatal, Postpartum, Frequency of Prenatal Care, Women’s Health and Well Child 0-15 months.
- Represent HPM at MIHP and EPSDT workgroup meetings.
- Assist in the development of new initiatives within Women and Children's services to improve the health and quality of care for pregnant women and newborns.
- Reviewing Boarder Baby Program:
- Follow up on boarder babies including all authorizations and appropriate referrals as needed.
- Assist with outreach and community efforts related to Women and Children’s Services including but not limited to:
- Community collaborative initiatives with providers
- Health fairs and/or baby showers within communities
- Community task force participation as requested
- Attendance at conferences including poster presentations and/or sharing of information with other team members related to educational opportunities
- Participation in Touchstar outreach campaigns as designated by department or Touchstar supervisor
- Develop skills and proficiency with PC based Microsoft Office applications, Windows and other applications particular to Health Plan of Michigan.
- Consistently demonstrates compliance with HIPAA regulations, professional conduct and ethical practice.
The successful candidate must be a Licensed LPN in the State of Michigan. One to two years experience in clinical or managed care nursing Experience with office functions including word processing, spreadsheets, mass mailings, etc.). Clinical experience in obstetrics preferred. Prior experience with HEDIS and NCQA a plus. Knowledge of managed care, Medicaid guidelines and Medical/obstetrical terminology.
POSITION REPORTS TO:Manager of Women & Children's Services
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