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 provide independent assessments and recommendations regarding medical necessity.
Assess treatment appropriateness through a holistic approach to patient wellness and offer alternative care options.
Build and maintain strong professional relationships with members, providers, staff, and management while collaborating with vendor case managers.
ASSIGNED DUTIES :
Serve as a clinical resource for MESSA's Medical Director, evaluating medical information and researching treatment options.
Educate members on navigating the health care system for informed decision-making regarding their care.
Assist in crafting personalized care plans for members and providers.
Authorize medical services and equipment based on assessed medical necessity.
Support case management program initiatives, including guideline research and implementation.
Coordinate care transitions across various health care settings.
Analyze costs for proposed treatment plans to recommend efficient options.
Collaborate with Member Services to clarify allowed amounts for nonparticipating facilities.
Evaluate eligibility for case management programs through thorough information review.
Work with the care team to implement individualized care plans based on nursing assessments.
Oversee the assignment and activities of External Case Management nurses.
Deliver education on MESSA plans and coverage details to External Case Management nurses.
Provide on-site assessment and member education at MESSA and MEA events.
Create custom member education presentations as needed.
Attend MEA / MESSA events after hours if necessary.
Maintain current nursing licensure with the Michigan Board of Professional Licensing.
Ensure compliance with all relevant regulations and accreditation standards.
Stay informed about nursing practices and pursue ongoing professional development.
Provide telephone support during holidays.
Exhibit knowledge and adherence to Case Management Standards of Practice and ethical codes.
Engage in quality improvement activities consistently.
Perform other duties as assigned.
MINIMUM REQUIREMENTS :
Bachelor of Science in Nursing (BSN).
Case management certification required within four years of employment; must be maintained thereafter.
Active Registered Nurse licensure in Michigan.
A minimum of two years in acute care, or two years in rehabilitation, case management, utilization review, discharge planning, mental health nursing, or disease management.
Excellent communication skills, both verbal and written.
Ability to adapt to a dynamic work environment.
Demonstrable clinical knowledge and experience in patient care.
Proficient in managing multiple tasks efficiently.
Ability to follow organizational policies and procedures.
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