- RN Case Management Coordinator, MercyCare Insurance, Days, 80 Hrs/2 wks
- Location: MercyCare Bldg, Janesville, WI
Case Management activities will be supervised by a Certified Case Manager (CCM) until CCM successfully obtained. Responsible for performing highly detailed complex case management (CM) activities for individual plan members. Able to perform a screening to determine if member has the potential to meet criteria for a full assessment and enrollment into Complex Case Management. Responsible for independently performing a complete assessment for the purpose of developing an Individualized Care Plan that address identified objectives and goals. Able to identify key team members for participation on individual member's Interdisciplinary Care Team. Appropriately uses metric tools to provide measurements on progress. Appropriately identifies evidence-based guidelines that should be followed for each individual complex case management participant. May also be responsible for coordinating and monitoring quality initiative and reviews including but not limited to, focus studies, clinical guidelines and preventative health guidelines. Attends and contributes as required to Health Plan committees such as Quality Taskforce and others assigned.
- Will spend no less than seventy-five percent of time providing direct case management activities on the phone, face to face, e-mail or other interactive methods
- Collects and assesses in depth information about a person's situation and functions to identify individual needs in order to develop a comprehensive individualized care management plan that will address those needs, meet goals and improve health outcomes
- 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 Twenty-five percent of time coordinating and monitoring non direct case management activities and administrative activities.
- Demonstrates knowledge of NCQA Complex Case Management requirements and evidence-based guidelines and where to locate the most effective guideline.
- 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 supervisor.
- Assists with developing and updating policy and procedures for the Quality Health Management Policy and Procedure Manual.
- Meets CMS standards of documentation and NCQA standards of documentation.
- Able to obtain written consent from members for program participation.
- Facilitates meetings and skillfully interacts professionally but in a persuasive manner with physicians and other health care providers.
- Achieves consensus on Individualized Care Plans.
Education and Experience
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.
Bachelor's degree preferred with two years related experience; or Associate Degree or Diploma Degree with four years related experience and/or training.
Licensed as an RN in state of practice
Certified Case Manager (CCM) or in the process of obtaining case manager designation
Special Physical Demands
The Special Physical Demands are considered Essential Job Function of the position with or without accommodations.
While performing the duties of this job, the employee is frequently required to sit. Specific vision abilities required by this job include close vision, peripheral vision and ability to adjust focus.
Culture of Excellence Behavior Expectations