RN Case Management Coordinator

Mercy-Health-System-Corporation; Janesville (WI); Hybrid; USD 64,000 - 97,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

FSA/HSA Options

Paid Time Off

Parental Leave

Tuition Reimbursement

Career advancement opportunities

Job summary

Mercyhealth is seeking an experienced Case Manager RN in Wisconsin to coordinate patient care, improve outcomes, and ensure NCQA/HEDIS compliance. The role focuses on developing individualized care plans, monitoring progress, and collaborating with providers and staff.

The position emphasizes education, policy adherence, and quality improvement within Mercyhealth’s clinical operations. The role requires a nursing degree, RN licensure, and preferred CCM certification, with a full-time schedule

Qualifications

• Graduate of an accredited nursing program.
• BSN or upon hire BSN completion agreement for enrollment in an accredited BSN Completion Program
• ADN RN or RN Diploma Degree preferred two years related experience.

Responsibilities

• Provide direct case management activities for members.
• Collects in depth information to develop comprehensive case management plans.
• Determine benefits/coverage of medical necessity per Mercyhealth policy.
• Execute interventions to achieve goals in the management plan.
• Monitor plan effectiveness and modify as needed.
• Educate provider offices and hospital staff on case management policies.
• Support quality initiatives and committee activities.

Skills

Case management

RN

CCM certification

Education

BSN preferred

ADN RN or RN Diploma

Job description

OVERVIEWExperienced Case Manager skilled in coordinating individualized care plans, improving member outcomes, and ensuring compliance with NCQA, HEDIS, and quality standards. Strong background in care coordination, quality improvement, and member-focused healthcare services.SCHEDULE: Full-Time, 40 hours per weekSHIFT: Day ShiftEssential Duties and ResponsibilitiesWill spend no less than sixty percent of time providing direct case management activitiesCollects in depth information about a person's situation and functions to identify individual needs in order to develop a comprehensive case management plan that will address those needs.Determines specific objectives, goals and actions designed to meet the clients' needs as identified through the assessment process; determines benefits/coverage of medical necessity based on MercyCare's medical certificate of coverageExecutes specific case management activities and or interventions that will lead to accomplishing the goals set forth in the case management plan.Organizes, integrates and modifies the resources necessary to accomplish the goals set forth in the case management planMonitors the ongoing process by gathering sufficient information from all relevant sources about the case management plan and its activities and determine the plans effectivenessEvaluates case managements effectiveness in reaching desired outcomes and goal and makes modifications or changes in the case management plan based on the evaluation.Participates as educator and resource person for provider offices and hospital staff as it pertains to the health plan case management policy and procedures.Will spend no more than forth percent of time coordinating and monitoring quality initiativeDemonstrates knowledge of NCQA and HEDIS Standards and participates in initiative to achieve accreditation and improve HEDIS compliance ratesAbility to assist with performing of case/barrier analysis, baseline study analysis and create Quality -Improvement studies and sound study design and interventionsAssists in the gathering and analysis of dataInsures that all activities are internal and external customer focused, well planned, organized and controlled to assure the cost effectiveness of all programs.Assists in the staff support activities of the UM/QI Committees and other special projects or tasks as assigned by the Medical Director or DirectorAssists with developing and updating policy and procedures for the Quality Health Management Policy and Procedure ManualCulture of Excellence Behavior ExpectationsTo perform the job successfully, an individual should demonstrate the following behavior expectations:Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.Education and ExperienceGraduate of an accredited nursing program.BSN or upon hire BSN completion agreement for enrollment in an accredited BSN Completion ProgramMay require specific years of applicable experience to qualify per department guidelines. If hired prior to 1-1-14 in Winnebago County and prior to 9-1-14 in Rock, Walworth and McHenry Counties an ADN only is required.ADN RN or RN Diploma Degree perfferred two years related experience.Certification and LicensureLicensed as an RN in state of practiceCertified Case Manager CCM or in the process of obtaining case manager designationSkills and AbilitiesDemonstrates knowledge of case management activities and core componentsProvide case management to members who meet specific criteria for specific disease managementDemonstrated ability to work within a team environmentMay include color blind test per department guidelinesSpecial Physical DemandsThe Special Physical Demands are considered Essential Job Function of the position with or without accommodations.While performing the duties of this job, the employee is frequently required to sit. Specific vision abilities required by this job include close vision, peripheral vision and ability to adjust focus.Level of SupervisionN/ASupervisesN/APAY RANGE:$63,644.48 - $97,376.06Mercyhealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identify, national origin, disability, or protected veteran status.Mercyhealth offers competitive pay and a comprehensive benefits package including:Medical, Dental, VisionLife & Disability InsuranceFSA/HSA OptionsGenerous, accruing paid time offPaid Parental and caregiver leaveCareer advancement and educational opportunitiesTuition and certification reimbursementCertification ReimbursementWell-being ProgramsEmployee DiscountsOn-Demand PayFinancial EducationAnnual recognition/awards eventsPartner appreciation daysFamily entertainment/attractions discountCommunity service/improvement opportunitiesClick here for more details regarding Mercyhealth Careers Benefit Information.At Mercyhealth, we don’t simply hire people, we empower employee-partners who are passionate about making lives better. As an integrated health system, we deliver exceptional, coordinated across seven hospitals, 85 primary and specialty clinics, and a team of over 7,500 professionals serving northern Illinois and southern Wisconsin.Mercyhealth has been nationally recognized for our commitment to our people and culture, including:#1 in the nation on AARP's Best Employers for Workers Over 50One of Working Mother magazine's 100 Best Companies for Working MothersA Top 50 Company and Top 10 Nonprofit for Executive Women