Case Manager RN - Hybrid at MyMichigan Health

Summary:

*This position is on-site/in-person initially with the potential for hybrid-remote schedule in the future.*

 

This position is responsible for active medical management that addresses the quality of care enrollees receive through coordinated quality improvement, utilization review, case management, disease management and wellness programs.  Duties include assessing medical necessity, quality, and cost effectiveness of proposed services in accordance with established criteria. Utilization review activity may be conducted prospectively, concurrently, or retrospectively and in collaboration with enrollees, physicians, and other professionals.  Through this review process, the nurse identifies those individuals and circumstances that would benefit from case management intervention.  This position provides case management services on behalf of individuals involving the essential activities and care components of case management, and is applied across a continuum of care in multiple environments.  

Responsibilities:

(40%) Determine whether a recommended intervention is the most appropriate treatment available for the enrollee. Use established criteria to make determinations, or make determination based on scientific evidence, professional standards, research, and expert opinion. Consult with Medical Director and medical management team as appropriate.

 

(30%) Compare the enrollee’s disease courses to established pathways to determine variances, and provide intervention as indicated.  Routinely assess enrollee’s status and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments in the plan of care, provider interventions and/or services to promote better outcomes.  Trend and identify areas of utilization patterns to evaluate opportunities for improvement/education.

 

(20%) Assess resource utilization and cost management; the diagnoses, past and present treatment; prognosis and goals (short and long-term).  Work cooperatively with Third Party Administrators to evaluate the medical condition of enrollees. Monitor prospective, concurrent, and retrospective utilization of services for all MyMichigan Health Network sponsored health plans that MHN is contracted to medically manage.

 

(10%) Assess and collect in-depth information about enrollee’s needs and level of functioning to develop a comprehensive case management plan.  Determine specific objectives, goals, and actions as identified through the assessment process.  Execute specific interventions that will lead to accomplishing goals established in the case management plan.  Organize, integrate, and modify the resources necessary to meet the goals established in the case management plan.  Gather sufficient information from all relevant sources to determine the effectiveness of the case management plan and the effectiveness in reaching desired outcomes and goals.  Negotiate fees, monitor appropriate cases and arrange services for the enrollee. Maintain communication and collaborate with enrollee, family, physicians, and health team members and payer representatives.  Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provider. Report quantifiable impact, quality of care and/or quality of life improvements as measured against the case management goals.  Provide case management functions and activities across the continuum of care and in whatever environment the enrollee is at any given time. Screen and refer quality issues as they arise to Medical Director or appropriate staff person.

Certifications and Licensures:

RN - Registered Nurse

Required      Equivalent Experience - Current unrestricted Michigan licensure as a Registered Nurse with 5+ years of clinical experience or BSN with 3+ years clinical experience is required.

Required Education:

Education: Associates Degree

 

Comments: A Registered Nurse with 5+ years of clinical experience or BSN with 3+ years clinical experience is required. One to two years of experience in a managed care setting is preferred.

Other Information:

OTHER DUTIES AND RESPONSIBILITIES

Care Management of chronic disease patients for all MyMichigan Health affiliated practices. 

 

Creates and maintains policies and procedures related to UM function.  Assists in designing, writing, implementing, and communicating all elements of the UM program.

 

Integral member of the National Committee for Quality Assurance (NCQA) team that works to assure compliance with NCQA UM standards in order to obtain initial and maintain ongoing organizational certification of ConnectCare’s UM program.

 

Quality Improvement:  Participate in development and assessment of QI activities. 

 

Schedule, perform and provide follow up for identified practitioner site reviews as part of the credentialing and recredentialing processes.

 

Communicate with practitioners and staff members about the MHN Medical Management program to increase awareness and participation.

 

 

Employer/Enrollee Communication: Assist in maintenance of on-going effective communication with employers/enrollees related to utilization/case management. 

 

Provide education as it relates to plan design and other services offered within the medical management program, including wellness programs and available community resources.

 

Privacy Officer:  Acts as the privacy officer and follows up as appropriate.

 

Miscellaneous duties as assigned: Duties may include participation in special projects as identified by the Medical Director and/or employer, for example, Wellness Programs, enrollee educational programs, etc.  Plan, develop and implement, as part of the MyMichigan Health Network team, NCQA Standards, staff recruitment, policies and procedures, etc.

 

MidMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft® Windows.  An employee may be required to participate in further learning opportunities offered by MyMichigan Health.

 

REQUIRED EDUCATION, EXPERIENCE, TRAINING AND SKILLS

Current unrestricted Michigan licensure as a Registered Nurse with 5+ years of clinical experience or BSN with 3+ years clinical experience is required. 

 

Excellent verbal and written communication skills, critical thinking, problem solving, strong computer skills, sound interpersonal and organization skills, and excellent time-management skills. 

 

Ability to interpret clinical information, understand implications for treatment and address issues that affect wellness. 

 

Ability to develop individualized plan of care based on the enrollee’s specific medical, psychological, financial and vocational issues. Understanding and respect for confidentiality, legal considerations, ethical issues and HIPAA rules relevant to patient care. 

 

Ability to function both independently and as part of a team.

 

Knowledge of various types of managed care organizations, insurance providers and administrators.  Awareness of various insurance lines and health benefit plans.  Familiarity with ICD9, CPT, DRG, and HCPCS coding.

 

Mandatory Occupational Safety and Health Administration (OSHA) training must be completed annually according to the Exposure Control Plan.

 

PREFERRED EDUCATION, EXPERIENCE, TRAINING AND SKILLS

 

One to two years of experience in a managed care setting is preferred.

 

PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS

Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.

 

Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.

 

Is able to move freely about the unit and hospital.

 

Overall vision is necessary; including reading, depth perception, close-up work and must have a peripheral field of vision.

 

Hearing and speech on the phone as well as in person are necessary.

 

Must be able to communicate verbally in person, on the phone and in writing.

 

Frequently required to sit/stand/walk for long periods of time.

 

Some exposure to blood borne pathogens and other potentially infectious material.

 

Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.

 

Must follow MyMichigan Health bloodborne pathogen and TB testing as required.

Equivalent Experience and Other Comments (Education):

 

 

Other Comments:

 

 

Apply Now