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
Janesville, WI – MercyCare
8:00am – 4:30 pm, Monday – Friday
Essential duties and Responsibilities
Must be able to function at a high level of independence using nursing knowledge, health plan/insurance knowledge, computer capability, excellent written/verbal communication, to meet turnaround times and prioritize work to facilitate timely and perform accurate utilization management activities for each product type. This will include being able to appropriately approve requests that do not need Medical Director input.
Capable of using or learning to use multiple computer programs information systems and web portals for the respective product/line of business.
Able to administer insurance benefits utilizing the Certificate of coverage, schedule of benefits, summary plan description, plan networks, appropriate policies and criteria, prior authorization process and referral process for admission, length of stay and requests for services to promote appropriate utilization as they relate to the different product types. Must be able to determine covered/non-covered services and how they relate to the appropriate documents. Must be able to appropriately assign services, number of visits and timelines.
Knowledge of NCQA standards, commercial requirements, Medicaid and Medicare requirements, and other product requirements. Participates with initiatives to achieve accreditation and improve HEDIS compliance rates and other quality measures as they relate to Utilization Management.
Must be able to assess medical information for continuing care needs, to facilitate transition of care and determine if a provider within the network can provide the requested service. Must be able to work with network and non-network providers to coordinate services that are covered benefits for the members. May need to develop and provide a utilization case management plan for a member as directed by the Medical Director, Manager or Team Leader.
Able to compose detailed letters to meet the specific requirements set forth in policies for different product types. Effective verbal communication with the ability to converse in a respectful and informative manner with co-workers, case management staff, physician offices and members, in accordance with the Mercy Health System partner behavior policy.
Assist in utilization, process improvement and/or quality activities of the various committees including Quality Initiatives Utilization Management committee, interdepartmental and departmental continuous quality improvement committees, and other special projects/tasks as assigned by the Medical Director, Manager or Team Leader.
Assist with developing and updating policy and procedures for the Medical Management Department to meet standards and commonly accepted medical practices by using the appropriate updated resources.
Assist with Quality Assurance case review.
Serve as a medical resource/consult for the MCHP appeal and grievance committee.
As part of the utilization process, may provide Case Management with a focus on case management practice.
Calculates and documents cost savings activities for utilization management, which will be reported to the Board of Directors.
Ensures all work activities are consistent with managed care policies and philosophy follows directives from the legal department and is responsible for all extra contractual arrangements.
Education and Experience
Graduate from an accredited nursing program.
BSN degree preferred or enrolled in a BSN program
One to two years of utilization management experience preferred
Registered Nurse, actively licensed in the state of Wisconsin
Current or able to obtain Professional Nurse Licensure for the state of Illinois
Internal Number: 19666
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 incentives