JOB SUMMARY Responsible for coordinating utilization review(UR), case management and NCQA/quality initiative activities for all managed products. Attends and contributes as required to physician committees such as medical management as assigned.
ESSENTIAL DUTIES AND RESPONSIBILITIES Demonstrates commitment to quality by providing excellent service to internal and external customers. 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. Completes work accurately and in a timely manner.
COMPETENCIES To perform the job successfully, an individual should demonstrate the following competencies : Quality- Follows policies and procedures.; Adapts to changes in the environment.; Demonstrates accuracy and thoroughness.; Looks for ways to improve and promote quality.; Applies feedback to improve performance.. Service- Responds promptly to requests for service and assistance.; Meets commitments.; Abides by MHS confidentiality and security agreement.; Shows respect and sensitivity for cultural differences.. Partnering- Supports organization's goal and values.; Exhibits objectivity and openness to other's views.; Gives and welcomes feedback.; Contributes to building a positive team spirit.; Generates suggestions for improving work.. Cost- Conserves organization resources..
EDUCATION, TRAINING, & EXPERIENCE CERTIFICATION/LICENSURE Registered Nurse, actively licensed in the state of Wisconsin, BSN degree preferred or enrolled in a BSN program; knowledge of health care delivery systems, medical necessity criteria application and legal consideration, surrounding managed care' proven excellence in communication; these skills include writing, speaking and presenting to professionals, demonstrates ability to work within a team environment.
OTHER SKILLS AND ABILITIES Excellent interpersonal communication skills Good organizational/analytical skills Able to perform under pressure
WORK ENVIRONMENT OSHA Exposure Category C. No Employees in the specified job classifications have occupational exposure The noise level in the work environment is usually quiet.
INFORMATION ACCESS Partner may access patient care information needed to perform their job duties. Partner may access financial data.
WORK CONTACT GROUP MercyCare Health Plans
LEVEL OF SUPV/SUPERVISES This job has no supervisory responsibilities. However, is responsible to make independent judgements, but alternatives are limited by standard practices or benefit levels.
Language Skills Ability to read, analyze, and interpret general business periodicals, technical procedures, or governmental regulations. Ability to write reports, business correspondence. Ability to effectively present information and respond to questions from team leaders, clients, customers, and the general public.
Mathematical Skills Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Reasoning Ability Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Computer Skills To perform this job successfully, an individual should have a high level knowledge or capacity to learn various database programs, software and Word Processing software.
Internal Number: 12316
Mercyhealth strives to provide a “best place to work” for its 8,000+ employee partners.
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
Our successful Culture of Excellence strategies have made Mercyhealth a health care leader in the region. We have been:
•Ranked #1 in the nation on the AARP Best Employers for Workers Over 50 list
•Named one of the Best Companies for Working Mothers by Working Mother magazine
•Named a Top 50 Companies and 10 Nonprofits for Executive Women by the National Association for Female Executives
We truly believe our accomplished staff is second to none and hope you’ll consider becoming part of the Mercyhealth family.
Mercyhealth is committed to offering our partners a best place to work and continually evaluates new programs and benefits. We have been recognized locally, regionally and nationally for helping our workers achieve a work/life balance through benefit offerings and innovative prog...rams.
For example, Mercyhealth was ranked #1 in the nation on the AARP Best Employers for Workers Over 50 list, a Best Company for Working Mothers by Working Mother magazine, and an adoption-friendly workplace by the Dave Thomas Foundation for Adoption, just to name a few.