Case Manager Registered Nurse Indiana
Job description
About Us
McLaren Health Care is a fully integrated health network committed to quality, evidence-based patient care with locations in Michigan, Indiana and Ohio. The McLaren system includes 14 hospitals in Michigan and Ohio, ambulatory surgery centers, imaging centers, a primary and specialty care physician network, commercial and Medicaid HMOs, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, one of only 51 National Cancer Institute-designated comprehensive cancer centers in the U.S.
MDwise, Inc. Opportunity – RN Case Manager
MDwise is your local, Indiana-based nonprofit health care company. We were founded in 1994 to help vulnerable populations needing health coverage in Indiana. Our parent organization, McLaren Health Care, is a nonprofit integrated health system who believes all Indiana families should have access to high quality health care regardless of income. Our mission is to provide high quality health care. MDwise works with the State of Indiana and Centers for Medicare and Medicaid Services to bring you the Hoosier Healthwise and Healthy Indiana Plan health insurance programs.
MDwise is seeking the right individual to join our team in our Medical Management department. As an employee of MDwise, you will be a part of a dynamic organization that considers all of our employees as leaders in driving the organization forward and delivering quality service to all our members.
Learn more about MDwise, Inc. at https://www.mdwise.org/
Position Summary:
Responsible for the review and authorization of all services to the members, utilizing expert knowledge of screening criteria, clinical criteria and research ability if no criteria exists. Uses independent judgment when necessary within scope of practice, including responsibility for medical management audits. Participates in the medical management of members in assigned product lines, including case specific and disease management programs, including catastrophic cases. Works with the PCP, the member and management to promote the delivery of quality services at the most appropriate and cost-effective setting. Performs as the member advocate with emphasis on education regarding managed care, disease management and PCP treatment plans. Monitors member’s utilization patterns for identification of high risk, and under and over use of services. Collaborates with Medical Director and senior management on complex cases and special projects.
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Qualifications:
Required:
- RN with a valid unrestrictive license from state employed in
- Three (3) years clinical nursing experience
- Two (2) years experience in Managed Care Utilization Management, Medical Management, Case Management
- Five (5) years experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions including understanding of claims administration, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc.
- BSN
- Certified Case Manager (CCM) Certification.
MDwise, Inc. is an Equal Opportunity Employer.
This is a remote position.
- Schedule: Full-time
- Requisition ID: 23000283
- Daily Work Times: Variable
- Hours Per Pay Period: 72
- On Call: No
- Weekends: Yes
Per Centers for Medicare & Medicaid Services (CMS) regulations, all McLaren employees must be vaccinated for COVID-19 by January 4, 2022. The regulation permits exemptions for employees with qualified medical disabilities or religious beliefs.
Equal Opportunity Employer
McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.
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