Position Summary
Responsible for managing treatment plan utilization and care under the guidance of the SVP and/ or Manager, Clinical Services and Consulting Chief Medical Officer. Reviews clinical records/outcomes to determine appropriateness of care and ensure Company and contract obligations are met.
Essential Functions
Critical features of this position are listed below and may be revised, updated or reassigned at management’s discretion in accordance with business needs or other factors.
- Consults with members and reviews medical treatment plans based on WIN’s medical and contract guidelines. Provides risk assessment assistance. Consults with Medical Director on unusual cases to determine appropriate action.
- Reviews non-standard service outcomes and enters outcomes into the Authorization Tracking System (ATS) ensuring entry of all required information.
- Encourages usage of WIN App to monitor points of care.
- Reviews data entered into ATS by Customer Service Agents (CSA) to ensure accuracy and completeness.
- Discusses plan of care, clarify, augment and/or confirm accuracy of information received from providers to ensure appropriate care, as necessary.
- Ensures providers are informed of patient needs, treatment modification, and/or progress when necessary or requested.
- Handles complex clinical issues or questions and troubleshoots clinical problems for the CSA team.
- Thinks strategically across the organization to improve processes and makes suggestions on improvements to the systems, telephone scripts, and processes.
- Tracks ART trends, quality of care, protocols and pathways, quality of service reviews to ensure WIN’s protocols are continually improving to meet or exceed ACOG, NANN guidelines.
- Utilizes knowledge of ATS, contract obligations, and best business practices to provide superior service to clients.
- Reviews benefit status based on customer plans and eligibility file information prior to engagement of services.
- Provides telephonic case management, education, and emotional support during the treatment process for members’ health plans, or employer groups.
- Provides support and appropriate referrals as needed.
- May perform other duties as assigned.
Supervisory Responsibilities
No direct supervisory responsibilities.
Minimum Qualifications
- Graduate of an accredited school of nursing with a minimum degree of Associates of Science. Bachelor of Science preferred.
- Current nursing license (and advanced practice license if applicable). Must be licensed to practice as a registered nurse in the state of residence.
- Minimum of five years’ experience in subspecialty including general infertility, IVF or infertility care management, women’s health. Mother/baby and/or NICU.
Knowledge, Skills, and Abilities
- Experience using MS Office products including Word and Outlook.
- Bilingual, Spanish or any other than English language desirable.