Cleveland Clinic Employee Health Plan Case Manager

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.

Under the supervision of the Manager, Care Management, Employee Health Plan (EHP), the Employee Health Plan Case Manager will be responsible for reviewing benefit coverage requests for services including inpatient, outpatient, equipment and supplies and imaging. You will also be case managing EHP members and their dependents, helping to transition members from one level of care to another.

The role requires the ability to work self-directed with minimal supervision in a work from home environment.

The ideal future caregiver is someone who:

• Has previous experience with medical insurance, claims and customer service.

• Independently problem solves and recognizes non-routine situations that should be brought to the attention of the supervisor/manager.

• Communicates in a professional manner, both verbally and written.

• Is proactive when observing possible barriers to the efficient and timely completion of department processes, workflows and tasks.

Within your first year of eligibility, you will be supported in becoming a Certified Case Manager.

At Cleveland Clinic, we know what matters most. That's why we treat our caregivers as if they are our own family, and we are always creating ways to be there for you. Here, you'll find that we offer: resources to learn and grow, a fulfilling career for everyone, and comprehensive benefits that invest in your health, your physical and mental well-being and your future. When you join Cleveland Clinic, you'll be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.

Job Responsibilities:

• Recommends resource utilization.

• Prioritizes and organizes work to meet changing priorities.

• Utilized analytical ability required to gather data. Uses clinical judgment to apply predetermined criteria.

• Applies medical necessity guidelines accurately to monitor appropriateness of items requiring prior authorization.

• Follows department guidelines on escalation processes to management and refers cases appropriately to the Medical Director.

• Maintains and supports collaborative relationships with multidisciplinary team members such as Customer Management Specialists, Pharmacy, Care Coordinators, Medical Directors, etc.

• Documents appropriately in Tapestry to provide evidence that the UR process for the referral was followed.

• Monitors in-network and out of network utilization of providers and services.

• Monitors for potential high dollar costs and redirects when appropriate.

• Coordinates transfer of care to in-network facilities for patients admitted to out-of-network facilities.

• Contacts recently discharged members via telephone per department protocol and interacts with all callers in a professional and courteous manner and follows established guidelines and document all interactions via EMR and department systems accurately.

• Serves as a liaison between health plan, patient and providers as needed.

• Other duties as assigned.

Education:

• Graduate from accredited school of Nursing with licensure as a Registered Nurse (RN).

• Bachelor of Science in Nursing preferred.

Certifications:

• Current state licensure as a Registered Nurse (RN).

• RN requires additional Multistate License (MSL) or eligible for MSL to be obtained within 90 days of hire.

• Certified Case Manager (CCM) preferred within the first year of eligibility.

• Basic Life Support (BLS) through American Heart Association (AHA).

Competencies:

• Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes.

• Analytical ability required to gather data, decide on conformity based on predetermined criteria, and identify problems and ref for resolution.

• Basic knowledge of medical records coding standards.

• Awareness of licensing and accreditation standards.

• Proficient with Microsoft Office.

• Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings preferred.

• Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other Utilization management criteria sets.

• Must possess advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.

• Expertise with electronic medical records preferred.

• Ability to work self-directed with minimal supervision in a work from home environment.

Work Experience:

• Three years relevant clinical experience required. May prefer specific clinical setting depending on area of assignment.

• One year of experience in a managed care setting, previous work with network providers, care coordination, case management or utilization management preferred.

Physical Requirements:

• Manual dexterity to operate office equipment.

• May require extended periods of sitting.

• Good visual acuity through normal or corrected vision and good audio acuity.

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment as required.

Salaries [which may be] shown on independent job search websites reflect various market averages and do not represent information obtained directly from The Cleveland Clinic. Because we value each individual candidate, we invite and encourage each candidate to discuss salary/hourly specifics during the application and hiring process.