STAFF RELATIONSHIP : Responsible to Health Care Resources Manager
EMPLOYMENT DATE : As soon as possible
BASIC PERFORMANCE EXPECTATIONS :
Utilize the nursing process and clinical expertise to serve as an independent resource for evaluating medical necessity.
Adopt a holistic approach to assess treatment appropriateness and recommend alternative care options.
Establish and maintain effective relationships with members, providers, staff, and management while collaborating with vendor case managers.
ASSIGNED DUTIES :
Serve as a clinical resource to other departments and medical directors for comprehensive medical evaluations and recommendations.
Guide and educate members in navigating the healthcare system for timely health care decisions.
Assist in the preparation and development of meaningful care plan alternatives with members and providers.
Authorize medical treatments and services based on a thorough evaluation of medical necessity.
Support the development of case management programs, maintaining up-to-date clinical practice guidelines.
Coordinate care transitions and interventions across various care settings.
Conduct cost analyses for proposed treatment plans or alternatives.
Work closely with the Member Services Benefits Administration staff on non-participating facilities and unique benefits.
Review eligibility for case management programs based on pertinent information.
Collaborate with patients, their designees, and healthcare providers to develop individualized care plans.
Delegate External Case Management nurse assignments efficiently.
Educate External Case Management nurses about MESSA plans and coverage details.
Monitor and assess the performance of External Case Management nurses, making adjustments as needed.
Provide on-site assessments and educational support at MESSA and MEA-sponsored events.
Create and deliver customized educational presentations for members as needed.
Participate in MESSA / MEA events outside normal business hours as applicable.
Ensure active registered nurse licensure with the Michigan Board of Professional Licensing.
Maintain compliance with all federal, state, and local regulations, as well as organizational standards.
Continually pursue professional development and competence in nursing practices.
Offer on-site telephone support during holiday periods.
Exhibit knowledge of the Case Management Standards of Practice and professional ethics.
Contribute to quality improvement activities.
Perform other duties as assigned.
MINIMUM REQUIREMENTS :
Bachelor of Science in Nursing (BSN).
Case management certification required within four years of employment, with ongoing maintenance thereafter.
Current, active Registered Nurse licensure in Michigan.
At least two years of recent experience in acute care, or two years in rehabilitation, case management, utilization review, discharge planning, mental health nursing, or disease management.
Exceptional verbal and written communication skills.
Ability to adapt in a dynamic work environment.
Strong clinical knowledge related to patient care and health delivery.
Professional demeanor in meetings.
Capability to work effectively in teams and independently.
Skill in managing multiple tasks efficiently.
Ability to adhere to organizational workflows, policies, and procedures.
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