Note: This position allows you the flexibility to work at home within the state of Ohio. We are looking for applicants that have a strong clinical case management background. Medicare experience is a plus.
Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.
Under limited supervision, the RN Case Manager evaluates and provides support to members, their families, and physicians in addressing member needs. Educates members and families to make informed personal health care decisions and determines the most effective treatment options. Facilitates communication between member, physician, and community.
Responsibilities
- Independently manages complex health care cases by multiple means such as phone, email, and video conferencing. Verifies eligibility, benefits, enrollment history, clinical history, and demographics. Assesses patient needs by gathering information from the member, family, provider, and other stakeholders to monitor and evaluate for medical appropriateness and quality of care. Educates members and assists them in removing barriers and with various treatment options.
- Facilitates and implements interventions based on agreed upon care treatment plan developed in collaboration with all participants in the members healthcare team. Coordinates services with community resources and support groups with members.
- Keeps up to date on and maintains appropriate documentation within Company and regulatory guidelines, policies, and practices.
- Performs other duties as assigned.
Qualifications
Education and Experience:
- Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor’s Degree preferred.
- 3 years as a Registered Nurse with a combination of clinical and case management experience, preferably in the health insurance industry.
- Case Management and Home health care experience is a plus.
Professional Certification(s):
- Registered Nurse with current State of Ohio unrestricted license. Multiple state licensure preferred and may be required.
- Certified Case Manager (CCM) or other industry recognized certification preferred (required within 3 years of hire).
- Certification in Motivational Interviewing preferred.
Technical Skills and Knowledge:
- In depth knowledge of health insurance benefits, health plans, and industry trends, and the ability to apply knowledge to achieve positive outcomes.
- Strong knowledge of behavioral change techniques and health coaching (ex. readiness to change and motivational interviewing)
- Knowledge of, and the ability to apply fundamental concepts related to HIPAA compliance and related regulations.
- Knowledge of disease continuums, expected patient outcomes and community services available.
- Intermediate proficiency navigating windows and web-based systems and basic Microsoft Office skills.
