McLaren Health Plan, recognized by Modern Health Care as one of the 100 Best Places to Work for four years in a row, has a need for RN Case Managers to join our growing Medical Management Team.
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.
RN with a valid unrestrictive Michigan license
Three (3) years clinical nursing experience
Two (2) years’ experience in Managed Care Utilization Management, Medical Management, Case Management
Must be knowledgeable and persuasive in interacting with medical providers, medical office staff, hospital/facility medical and administrative staff, payors/health plans and members.
Understanding of claims administration, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc
Five (5) years’ experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions (e.g. accounting/finance, reinsurance, EDI, marketing, administration, medical delivery, regulatory compliance, claims processing, membership/eligibility, contracting and risk arrangements and actuarial precepts)
Bachelor’s Degree in business, health care or related field. An equivalent combination of relevant education and experience may be substituted for the educational requirement
Certified Case Manager (CCM) Certification
To further our mission of enhancing the health status of the individuals and communities we serve, effective February 1, 2013,?McLaren Health Plan will no longer hire individuals who use tobacco or nicotine products in any form. Cotinine testing will be used to verify non-tobacco use. Individuals whose health screening results are verified positive for tobacco/nicotine use will be disqualified from employment, their job offer will be rescinded, and they will be disqualified from reapplying for employment for six (6) months from the date of the health screening.
McLaren Health Care is a fully integrated health network, committed to quality, evidence-based patient care and cost efficiency. The McLaren system includes 12 hospitals, ambulatory surgery centers, imaging centers, freestanding dialysis centers, a regional network of cancer centers and providers, an employed primary care physician network, assisted living facilities, commercial and Medicaid HMOs, home health care and hospice, durable medical equipment and a wholly-owned medical malpractice insurance company. McLaren has 19,500 employees and more than 20,000 network physicians. The National Committee for Quality Assurance (NCQA) has awarded McLaren Health Plan's Medicaid HMO and Commercial-HMO/POS Combined products, an accreditation status of Commendable for service and clinical quality that meet NCQA's rigorous requirements for consumer protection and quality improvement.McLaren Health Plan has been awarded several Pinnacle Awards for Best Practices from the Michigan Association of Health Plans (MAHP) in a variety of categories:2003 - PCP Case Management2004 - ABAD (Assistance for the Blind and Disabled) Lets Connect2005 - Disease Management for Well Children Population2006 - Comm...unity Outreach to Prevent Lead Poisoning ("Not in My Back Yard")2007 - Chronic Disease Care2008 - You've Got a Nurse (commercial business) 2010 - Early Care Health Families2011 - MedCheck (commercial business)2012 - Taking it Off weight management program (commercial business)