Health Insurance Case Management Jobs in Wisconsin

OVERVIEW

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.

SCHEDULE: Full-Time, 40 hours per week

SHIFT: Day Shift

Essential Duties and 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

Culture of Excellence Behavior Expectations

To perform the job successfully, an individual should demonstrate the following behavior expectations:
Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.
Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.
Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.
Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.

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.
ADN RN or RN Diploma Degree perfferred two years related experience.

Certification and Licensure

Licensed as an RN in state of practice
Certified Case Manager CCM or in the process of obtaining case manager designation

Skills and Abilities
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
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.

Level of Supervision

N/A

Supervises

N/A

PAY RANGE:

Mercyhealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, disability, or protected veteran status.

Mercyhealth offers competitive pay and a comprehensive benefits package including:

• Medical, Dental, Vision

• Life & Disability Insurance

• FSA/HSA Options

• Generous, accruing paid time off

• Paid Parental and caregiver leave

• Career advancement and educational opportunities

• Tuition and certification reimbursement

• Certification Reimbursement

• Well-being Programs

• Employee Discounts

• On-Demand Pay

• Financial Education

• Annual recognition/awards events

• Partner appreciation days

• Family entertainment/attractions discount

• Community service/improvement opportunities

Click here for more details regarding Mercyhealth Careers Benefit Information.

At Mercyhealth, we don't simply hire people, we empower employee-partners who are passionate about making lives better. As an integrated health system, we deliver exceptional, coordinated across seven hospitals, 85 primary and specialty clinics, and a team of over 7,500 professionals serving northern Illinois and southern Wisconsin.

Mercyhealth has been nationally recognized for our commitment to our people and culture, including:

• #1 in the nation on AARP's Best Employers for Workers Over 50

• One of Working Mother magazine's 100 Best Companies for Working Mothers

• A Top 50 Company and Top 10 Nonprofit for Executive Women