Women & Children's Outcomes Specialist II

Job Summary:

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

Education and Experience:

• 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
• Medicare/Medicaid experience preferred

Competencies, Knowledge and Skills:

• 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

Licensure and Certification:

• Employment in this position is conditional pending successful clearance of a driver’s license record check.  If the driver’s license record results are unacceptable, the offer will be withdrawn or, if employee has started employment in position, employment in the position will be terminated
• 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. Request for accommodations will be completed through an interactive review process.

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Required to use general office equipment, such as a telephone, photocopier, fax machine, and personal computer
• Flexible hours, including possible evenings and/or weekends as needed to serve the needs of our members and may refer members to other CareSource resources
• AWL and/or Office Location

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business