Summary/Objective:

The RN Case Manager will be a member of the care coordination team within Access Health and provide onsite and telephonic case management services. This position will serve as the primary point of contact for members with the goal of improving quality outcomes and optimizing service utilization and cost. The position will incorporate education to staff, members, and the community on chronic condition diseases and will incorporate the domains of health, and community resources.

Principal Responsibilities:

· Assess new members and existing members and incorporate the medical component into the Comprehensive Health Improvement Plan (CHIP).

· Update and revise the CHIP when appropriate utilizing the member and health coach “Health Scores” within the domain section of the CHIP and make referrals to appropriate community resources as needed.

· Evaluate the need for new programs in the community and be an active member in the creation and success of those programs.

· Educate members, health coaches and other staff members about individual health care plans and available community options.

· Make clinical decisions in regard to authorizations per the policy guidelines.

· Oversee quality components (disease management, utilization management, and accreditation and wellness programs).

· Reviews policies, procedures, and protocols no less than annually and revises as necessary with approval from the Medical Director.

· Review new standards of care and bring suggestions to the Medical Director.

· Provide guidance for clinical operational and is responsible for oversight of clinical decision-making aspects of the clinical and wellness programs.

· Provide leadership and direction in the implementation of projects initiatives to ensure goals are met and provide value of service for plans and customers. Collaborate with others in the organization to ensure project team efforts accomplish objectives in a timely and successful manner.

· Liaison between community, physicians, outside organizations, and staff.

· Identify and communicate appropriate, available community resources to members and the staff.

· Evaluate and report the outcomes of care coordination programs and/or individual care coordination activities.

· Report and communicate utilization variances.

· Provide clinical expertise in individual benefit interpretations, consistent with established Access Health plan benefit policies.

· Chair and participate in multidisciplinary team conferences as needed.

· Coordinate cross-functional issues related to utilization, quality, potential fraud and abuse, and related issues.

· Coordinate with the AHI Medical Director or physician designated regarding potential denial of services or quality of care issues.

· Develop and implement new case management and disease management programs.

· Keep abreast of changing health delivery and health promotion systems.

· Develop and manage educational programs, assure programs are cost-effective and at the most appropriate level, collaboration with community resources.

· Coordinate Clinical subcommittee meetings of the AHI Board of Directors.

· Coordinate and facilitate the clinical requirements for grant programs, both internally and externally.

· Establish and carry out departmental and organizational goals, policies, and procedures.

· Initiate, develop and maintain relationships with key community partners and customers.

· Responsible for coordinating and promoting the expansion of C3 Health Plan as a product in other communities.

Shared Responsibilities of all Staff:

· Act and make decisions in accordance with Access Health’s Guiding Principles.

· Understand ethical behavior and business practices and ensure that own behavior and the behavior of others is consistent with these standards and aligns with the values of the organization.

· Demonstrate a willingness to be flexible, versatile and/or tolerant in a changing work environment while maintaining effectiveness and efficiency.

· Establish and maintain positive working relationships with others, both internally and externally, to achieve the goals of the organization.

· Work cooperatively and effectively with others to set goals, resolve problems, and make decisions that enhance organizational effectiveness.

· Speak, listen and write in a clear, thorough and timely manner using appropriate and effective communication tools and techniques.

· Develop new and unique ways to improve operations of the organization and to create new opportunities.

· Utilize systems and procedures to maximize productivity.

· Anticipate, understand, and respond to the needs of internal and external clients to meet or exceed their expectations within the organizational parameters.

· Report suspected fraud and abuse to Supervisor, or the Compliance Officer, immediately.

· Use and Disclose Protected Health Information (PHI) in accordance with established Company policies and procedures and HIPAA guidelines.

· Comply with federal and state laws as well as Company policy and procedures.

· Other duties as assigned.

Required Education and Experience

· Registered Nurse with a current, valid license in the State of Michigan

· Three to five years case management experience.

· Proficient computer skills including experience with Microsoft Office, e-mail, and the Internet.

Preferred Education and Experience

· Bachelor’s degree in Behavioral Health or Health Care Administration preferred, or equivalent experience.

· National Certification in an ANA Specialty (i.e. Diabetes, Asthma/COPD, Mental Health, and Managed Care) preferred.

· CCM preferred.

· Managed care experience, minimum of three years. May substitute community health experience.

· Experience in health care and managed care preferred.

Position Related Skills/Competencies and Desirable Characteristics

· Experienced in effective instruction, facilitating performance, motivational interviewing and motivational support.

· Maintains knowledge of up-to-date view of health systems change, population health, information technology, and healthcare financing models.

· Proven ability to foster collaborations and inspire confidence and motivate groups to collectively meet common objectives.

· Experience with setting priorities, developing a work schedule, monitoring progress towards goals, and track details, data, information, and activities.

· Demonstrated track record for sustained measurement of program outcomes.

· Knowledge of regulatory and compliance guidelines.

· Ability to facilitate change.

· Proven ability to assess situations and effectively determine the importance, urgency and risks, and make clear decisions which are timely and in the best interests of the organization.

· Experience determining strategies to move the organization forward, set goals, create and implement actions plans, and evaluate the process and results.

· Knowledge of leadership and management principles as they relate to non-profit/ voluntary organizations.

· Knowledge of current community challenges and opportunities relating to the mission of the organization.

· Ability to perform independently, with limited direction. Effective organizational and prioritizing skills.

· Enthusiasm and commitment to our Mission, Vision, Values, and Guiding Principles.

· Ability to facilitate meetings, lead training sessions, and make presentations to small and large groups.

· Ability to speak, write, and document information accurately and effectively.

· Valid Michigan Driver’s License.

Work Environment

This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

This is largely a sedentary role; however, some filing is required. This would require the ability to lift files, open filing cabinets and bend or stand as necessary.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are Mondays through Friday of each week, from 8am to 5pm in our Muskegon Office.

Travel Travel is primarily local during the business day, although some out-of-area and overnight travel may be expected.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Job Type: Full-time

Pay: $68,000.00 - $80,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Flexible spending account
• Health insurance
• License reimbursement
• Life insurance
• Mileage reimbursement
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Holidays
• Monday to Friday
• No weekends

Work setting:

• Office

Ability to Relocate:

• Muskegon, MI 49442: Relocate before starting work (Required)

Work Location: In person