SEND MESSA APPLICATION AND COPY OF DEGREE OR TRANSCRIPT SHOWING PROOF OF DEGREE TO: [email protected]
Position Summary:
Under the direction of the Health Care Relations Manager, independently apply the nursing process and evidence-based clinical knowledge for medical-necessity determinations. Serve as a resource to all Member Services non-clinical staff, other MESSA department staff and vendors. Provide case management services to MESSA members to ensure they have support, education, and guidance needed to make informed healthcare decisions.
This job requires the ability to establish and maintain effective and inclusive working relationships with consultants, members, vendors, staff, and management.
Essential Job Functions:
An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the job-related duties which the employee may be expected to perform. To perform this job successfully, an individual must be able to perform each essential function satisfactorily.
1. Act as a clinical resource to non-clinical MESSA staff in reviewing medical information and providing appropriate determinations for medical necessity.
2. Collaborate with the medical director, management, and other clinical team members.
3. Provide education and guidance to members and their designees in accessing and navigating the health care system, and exploring treatment options that support a member’s timely and informed health care decision.
4. Authorize medical treatments, services and equipment based on medical necessity in accordance with policies, procedures, and guidelines. Negotiate member service or equipment rates/pricing as appropriate.
5. Support the ongoing development and implementation of case management programs and initiatives including the research, investigation, and maintenance of clinical practice guidelines.
6. Actively participate in the Quality Management and Improvement Committee and support quality improvement activities.
7. Coordinate care transitions, interventions, treatment, services, and resources across care settings.
8. Review and evaluate all pertinent information to determine appropriateness and eligibility for case management programs.
9. Review and evaluate all pertinent information to determine appropriateness and medical necessity for hospital admissions.
10. Using the nursing process, collaborate with the member, member’s designee, and health care team to develop, implement, and evaluate an individualized care plan.
11. Collaborate with other MESSA teams and departments as needed to resolve member inquiries.
12. Provide ongoing coaching, feedback, and directives to external case management nurses and non-clinical staff.
13. Develop and present staff and member education presentations as requested.
14. Assist in the maintenance of policies, procedures, workflows, job aids and templates as needed/requested in accordance with accreditation standards.
15. Maintain compliance with federal, state, and local rules and regulations, and organizational accreditation and certification standards.
16. Maintain knowledge and competence in Nursing Scope and Standards of Practice, Case Management Standards of Practice and the Code of Ethics and Professional Conduct for Case Managers.
17. Maintain timely and accurate, high-quality documentation.
18. Maintain confidentiality in accordance with HIPAA and organizational policies.
19. Attend MESSA/MEA events outside of business hours as needed.
20. Participate in projects, committees, and teams as needed.
21. Perform other job-related duties as assigned.
SEND MESSA APPLICATION AND COPY OF DEGREE OR TRANSCRIPT SHOWING PROOF OF DEGREE TO: [email protected]
Required Knowledge, Skills, Abilities and Minimum Qualifications:
The requirements listed below are representative of the knowledge, skills, abilities, and minimum qualifications necessary to perform the essential functions of the position. Reasonable accommodations may be made to enable individuals with disabilities to perform the job.
· Bachelor of Science in Nursing (BSN) required.
· Registered nursing license with the Michigan Board of Professional Licensing required. Must maintain licensing in good standing throughout employment.
· Ability to acquire and retain certification in Case Management within four years of becoming a nurse coordinator required.
· At least two years of acute care clinical experience.
· At least two years’ broad clinical experience including but not limited to the following settings: rehabilitation, case management, utilization review, discharge planning, mental health nursing, or disease management required.
· Experience and/or familiarity with an accreditation process preferred.
· Demonstrated clinical knowledge and experience relative to patient care and health delivery processes.
· Strong verbal communication abilities with members, diverse groups of staff, management, directors, and vendors.
· Knowledge of correct spelling, English usage, grammar, and punctuation skills.
· Knowledge of the structure, policies, procedures, and regulations of MESSA.
· Advanced level proficiency in the use of office equipment and technology, including computers and related software, and ability to master new technologies.
· Ability to set priorities, juggle multiple priorities and establish appropriate task and project deadlines and meet them.
· Ability to exercise sound and mature judgment, especially in crisis situations.
· Ability to successfully negotiate fair agreements, when possible, with vendors and providers for medically necessary services and equipment.
· Ability to establish effective working relationships and use good judgement, initiative and resourcefulness when negotiating and dealing with members, vendors, staff, and management.
· Ability to critically assess situations, problem-solve, exercise a high degree of diplomacy, and work effectively under stress, within deadlines and changes in work priorities autonomously as well as within a group.
Physical Demands and Work Environment:
The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential duties of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
While performing the duties of this job, the employee regularly works in an office setting with a controlled climate where they sit and work on a computer, communicate by telephone, email, or in person, and move around the office to travel to other locations. The employee must occasionally lift and/or move items of moderate to heavy weight. The noise level in the work environment is usually quiet. The employee occasionally travels to other locations to attend department functions when necessary. This may require overnight stays away from home.
Last Updated: January 1, 2025
SEND MESSA APPLICATION AND COPY OF DEGREE OR TRANSCRIPT SHOWING PROOF OF DEGREE TO: [email protected]
Pay: From $29.24 per hour
Benefits:
- 401(k)
- Dental insurance
- Employee assistance program
- Health insurance
- Paid sick time
- Paid time off
- Parental leave
- Retirement plan
- Tuition reimbursement
- Vision insurance
Work Location: In person
