RN Case Management Coordinator

Mercyhealth•Janesville, WI

4d•Onsite

About The Position

Experienced Case Manager skilled in coordinating individualized care plans, improving member outcomes, and ensuring compliance with NCQA, HEDIS, and quality standards. Strong background in care coordination, quality improvement, and member-focused healthcare services.

Requirements

Graduate of an accredited nursing program.
BSN or upon hire BSN completion agreement for enrollment in an accredited BSN Completion Program
May require specific years of applicable experience to qualify per department guidelines.
If hired prior to 1-1-14 in Winnebago County and prior to 9-1-14 in Rock, Walworth and McHenry Counties an ADN only is required.
ADN RN or RN Diploma Degree perfferred two years related experience.
Licensed as an RN in state of practice
Certified Case Manager CCM or in the process of obtaining case manager designation
Demonstrates knowledge of case management activities and core components
Provide case management to members who meet specific criteria for specific disease management
Demonstrated ability to work within a team environment
May include color blind test per department guidelines

Responsibilities

Will spend no less than sixty percent of time providing direct case management activities
Collects in depth information about a person's situation and functions to identify individual needs in order to develop a comprehensive case management plan that will address those needs.
Determines specific objectives, goals and actions designed to meet the clients' needs as identified through the assessment process; determines benefits/coverage of medical necessity based on MercyCare's medical certificate of coverage
Executes specific case management activities and or interventions that will lead to accomplishing the goals set forth in the case management plan.
Organizes, integrates and modifies the resources necessary to accomplish the goals set forth in the case management plan
Monitors the ongoing process by gathering sufficient information from all relevant sources about the case management plan and its activities and determine the plans effectiveness
Evaluates case managements effectiveness in reaching desired outcomes and goal and makes modifications or changes in the case management plan based on the evaluation.
Participates as educator and resource person for provider offices and hospital staff as it pertains to the health plan case management policy and procedures.
Will spend no more than forth percent of time coordinating and monitoring quality initiative
Demonstrates knowledge of NCQA and HEDIS Standards and participates in initiative to achieve accreditation and improve HEDIS compliance rates
Ability to assist with performing of case/barrier analysis, baseline study analysis and create Quality -Improvement studies and sound study design and interventions
Assists in the gathering and analysis of data
Insures that all activities are internal and external customer focused, well planned, organized and controlled to assure the cost effectiveness of all programs.
Assists in the staff support activities of the UM/QI Committees and other special projects or tasks as assigned by the Medical Director or Director
Assists with developing and updating policy and procedures for the Quality Health Management Policy and Procedure Manual