What are the responsibilities and job description for the Nurse Case Manager Remote -- MediGold Health Plan position at Mount Carmel Health System?
Why MediGold?
MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.
We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing.
Position Purpose:
The RN Case Manager MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member’s family and other resources as appropriate. Assists in the implementation of Case Management software along with the Plan’s UM and QM Program and the review of the Plan’s Medical Management Plan.
Minimum Qualifications:
- Education: Associate Degree in Nursing. Bachelor’s Degree as appropriate.
- License / Certification: RN with current unrestricted state licensure required Creates a caring and healing environment that keeps the member and family at the center of care throughout their experience with MediGold.
- Experience: Minimum of 5-7 years of clinical nursing experience with at least 2 years experience in utilization review, discharge planning, case management, disease management or medical social work experience required. Nursing experience in an HMO insurance company setting preferred. e.
- Demonstrated ability to analyze, summarize and concisely report medical utilization, and medical chart audit results.
- Ability to compare approved criteria with clinical information to determine appropriateness of service and to document all related information according to department policies and procedures.
- Conducts claim review as required for appropriate claims processing.
- Ability to implement and successfully utilize Case Management software.
What we're looking for:
- Coordinates with case management resources to assure development and documentation of a treatment plan for members who meet the Plan’s guidelines for Case Management and communicates the plan to the member’s PCP and other members of the care team.
- Completes an initial assessment of the member’s health status, including medical history, medications, symptoms, degree of support from family & friends, and current treatment prescribed by the member’s physician.
- Consults with member to set negotiated goals and determine the frequency of interaction.
- Provide telephone follow up at the frequency agreed upon and teaching to promote goal attainment as well as providing educational materials appropriate for that member’s condition.
- Assist member to be an advocate for their healthcare and assist with formulating questions to ask the physician, as well as how to respond to common symptoms they might experience.
- Participates in designated committees and task forces at the direction of the Supervisor and Sr. Director of Medical Management.
- Coordinates with the utilization review, case management, discharge planning staff within network facilities.
- Creates and maintains a case management database of referrals and treatment plans for Members.
- Coordinates with Medical Director/Associate Medical Directors on case-specific issues.
- Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues.
- Conducts inpatient concurrent review.
- Documents and communicates to QM staff appropriately all identified quality concerns related to Members.
Position Highlights and Benefits:
- Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
- Retirement savings account with employer match starting on day one.
- Generous paid time off programs.
- Employee recognition programs.
- Tuition/professional development reimbursement.
- Relocation assistance (geographic and position restrictions apply).
- Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing.
- Employee Referral Rewards program.
- Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!
- Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.
Ministry/Facility Information:
Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our four hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
