Experience a rewarding and fulfilling career with Mercyhealth. Mercyhealth is committed to offering our partners a best place to work. Our unique workplace Culture of Excellence is built upon:
Employee engagement, empowerment and growth
Teamwork toward our common goal – providing exceptional health care services with a passion for making lives better
An atmosphere of caring and quality that cascades throughout the organization
Supervise Utilization Management, Case Management and Quality Health Specialists of the Quality Health Management Department (QHMD). The Manager is responsible for planning, organizing, and managing the assigned operations for utilization management and case management services. The Manager coordinates with appropriate personnel to meet operational program needs, ensures compliance with contractual, state and federal health plan requirements, Medicare and Medicaid guidelines and NCQA standards. Develops, implements, and maintains policy and procedures. Updates and integrates current clinical practice guidelines. Performs partner coaching, performance appraisals, and oversees partner training and development. The position requires the ability to foster communication and team work in the department and between physicians, marketing, customer service, claims, quality, corporate departments, vendors and senior leadership. The manager will assist senior leadership with long-term planning initiatives to maintain operations ensuring activities are appropriately integrated into strategic direction as well as the mission and values of the company. Other duties may be assigned.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Supports the activities and goals of the Medical Director.
Participates, provides input and impacts on outcomes of the following; Medical Management Committee, Population Health Management Task Force, Internal committees and other committees as assigned. May need to attend off site meetings.
Responsible for data collection, planning, reporting, and implementing success initiatives with each line of business, including but not limited to Overall Health Care Cost PMPM; Quality of Care Metrics as it relates to Population Health Management; Acute patient care episodes through admits, readmits, ER visits, and referrals.
Coordinates all activities and policy development related to contractual, state and federal regulatory requirements.
Directs, plans, and supervises activities for Utilization Management, Case Management and Quality Health Specialist staff teams in an efficient and effective manner utilizing time management skills to facilitate the total work process. Provides constructive information to minimize problems and increase customer satisfaction. Spends time with each area to mentor, foster working relationships and provide education needs.
Provides effective problem solving, serves as a liaison and resource with internal and external customers to provide optimal customer satisfaction.
Maintains current knowledge of health plan benefits and provider networks. Guides internal and external providers on preferred providers and facilities.
Participates in the development, planning and execution of continuous quality improvement (CQI) efforts, policies and procedures, and regulatory compliance functions related to Quality Health Management Department activities. Develops initiatives for process improvement for the Quality Health Management Department.
Develops new policies, procedures, job aids, and work flows that enhance operating efficiency of the care management program or activities;
Evaluates the success of process improvement efforts and implements solutions for growth opportunities.
Evaluates care management staff performance by performing, at a minimum, one on one individual meeting every other month. Provide coaching for performance success. In coordination with HR consistently execute disciplinary actions/Performance Improvement Plans.
Interviews, hires and retains quality staff to meet the business needs.
Ensures the timely preparation of reports and records for dissemination to appropriate stakeholders.
Completes and/or provides input on budget.
Will need to be able to walk or drive to various meetings on time.
Must be able to cognitively function at a high level.
Has familiarity with components of a Magnet environment and is supportive of all initiatives within the structure.
EDUCATION & EXPERIENCE
Bachelor of Science in Nursing required
5 + years of varied clinical experience
5+ years of experience in the managed care, disease/utilization management, case management with a minimum of three years at the management level or above
2+ years of experience with Epic/ Tapestry Referral program.
Broad Knowledge of federal and state laws relating to health care and insurance companies in MercyCare service areas.
Experience in NCQA regulation relating to managed care, disease management, utilization management, transition planning and complex case management
Knowledge of basic principles and practices of clinical nursing
Broad Knowledge of referral processes, claims, case management and physician practices as related to Insurance Industry.
Knowledge of fiscal management and human resource management techniques
Excellent written and verbal communication skills
Extremely proficient with computer software programs including Microsoft Office, to include spreadsheets and graphics, databases
Masters degree in nursing, healthcare administration or business administration
10+ years of experience in managed care and/or population health management with a minimum of five years at a management level
Registered Nurse with license in Wisconsin and Illinois and/or ability to obtain licensure in these states.
Commission for Case Management Certification as a Certified Case Manager (CCM) or American Case Management Association (ACMA) as an Accredited Case Manager (ACM) or American Association of Managed Care Nurses as a Certified Managed Care Nurse (CMCN) or meets the requirements to become certified within 6 months of hire.
Internal Number: 19710
Mercyhealth is a non-profit regional health care organization with more than 8,000 employee partners, 5 major hospitals, and 80 facilities and clinics throughout the Northern Illinois and Southern Wisconsin region. We are committed to being a top integrated health care provider and continuously work to make life better for the people, families and communities we serve.
Our partners serve with compassion, dedication, pride and professionalism. Our culture focuses on employee engagement, empowerment and growth, working together as a team to achieve one common goal: our mission of providing exceptional health care services, resulting in healing in the broadest sense and a best-in-class place to work for our partners.
We place great importance on providing our partners the tools, resources, facilities, and support to create lifelong career opportunities with an emphasis on a rewarding work-life balance. We achieve this by offering partners:
• Competitive compensation and benefits
• Tuition and certification reimbursement
• Generous PTO accruals
• Career ladder and advancement opportunities
• Partner recognition days and achievement awards
• Local/regional discounts and incen...tives
At Mercyhealth, we serve with a passion for making lives better, and we truly believe our accomplished staff is second to none in this mission. We hope you’ll consider becoming part of the Mercyhealth family.
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