Use the nursing process and clinical knowledge to act as an independent resource for determinations and recommendations of medical necessity.
Use a comprehensive, holistic approach to the illness/wellness continuum to determine the appropriateness of the planned treatment, and to evaluate and recommend alternative treatments and care options.
Demonstrate the ability to establish and maintain effective working relationships with members, providers, staff and management, along with ongoing collaboration with vendor case managers.
Act as a clinical resource to other departments and MESSA’s Medical Director in reviewing and evaluating all pertinent medical information, including researching treatments, modalities, and procedures in order to provide appropriate recommendations.
Educate and guide members and their designees in accessing and navigating the health care system so they can make timely and informed health care decisions.
Assist members and providers in preparing and developing appropriate care plan alternatives.
Authorize medical treatments, services and equipment based on medical necessity.
Support the ongoing development and implementation of case management programs and initiatives including the research, investigation, and maintenance of clinical practice guidelines.
Coordinate care transitions, interventions, treatment, services, and resources across care settings.
Develop and review cost analyses for proposed treatment plans or alternatives.
Collaborate with the Member Services Benefits Administration staff in determining allowed amounts for nonparticipating facilities and Medical Case Management unique benefits.
Review and evaluate all pertinent information to determine appropriateness and eligibility for case management programs.
Using the nursing process, collaborate with the member, member’s designee, physician, hospital and other appropriate agencies to assess the patient's condition and to develop, implement and evaluate an individualized care plan.
Assign External Case Management nurses appropriately.
Educate and instruct External Case Management nurses regarding MESSA plans, coverage availability, and limitations.
Monitor, direct, and evaluate External Case Management nurse activities and implement changes as needed.
Provide on-site assessment and education to members attending MESSA and MEA-sponsored events in the field.
Develop and present customized member education presentations as requested.
Attend MESSA/MEA events outside of business hours as needed.
Maintain current registered nurse licensure with the Michigan Board of Professional Licensing.
Maintain compliance with federal, state and local rules and regulations, and organizational accreditation and certification standards.
Pursue professional knowledge and maintain competence in Nursing Scope and Standards of Practice.
Provide on-site telephone support during holiday periods.
Demonstrate knowledge, skills, and competency in the application of the Case Management Standards of Practice, and the Code of Ethics and Professional Conduct.
Support systematic approaches to quality improvement activities.
Other duties as assigned.
Bachelor of Science in Nursing (BSN).
Case management certification within four years of becoming a Nurse Coordinator and maintain this certification thereafter.
Current, active Registered Nurse licensure with Michigan Board of Professional Licensing.
Minimum two years of recent experience in acute care,
Experience to include at least two years in any of the following: rehabilitation, case management, utilization review, discharge planning, mental health nursing, or disease management.
Exceptional verbal and written communication skills.
Ability to adapt effectively to the ever-changing nature of the work.
Demonstrated clinical knowledge and experience relative to patient care and health delivery processes.
Ability to participate in meetings in a professional manner.
Work in a team environment as well as autonomously.
Ability to manage multiple tasks simultaneously.
Ability to follow department and organization workflows, policies and procedures.
About Michigan Education Special Services Association
MESSA's mission is to serve the members of the Michigan Education Association by providing comprehensive health and related employee benefit plans which respond to the financial and special requirements of the membership, with a continued commitment to personalized service.