McLaren Health Care Case Manager RN in Indianapolis, Indiana
MDwise, Inc. Opportunity – Case Manager RN
MDwise is your local, Indiana-based nonprofit health care company. We were founded in 1994 to help vulnerable populations needing health coverage in Indiana. Our parent organization, McLaren Health Care , is a nonprofit integrated health system who believes all Indiana families should have access to high quality health care regardless of income. Our mission is to provide high quality health care. MDwise works with the State of Indiana and Centers for Medicare and Medicaid Services to bring you the Hoosier Healthwise and Healthy Indiana Plan health insurance programs.
MDwise is seeking the right individual to join our team in our Medical Management department. As an employee of MDwise, you will be a part of a dynamic organization that considers all of our employees as leaders in driving the organization forward and delivering quality service to all our members. This is a telecommuting opportunity - we will come to your Indiana or Michigan neighborhood!
Learn more about MDwise, Inc. at https://www.mdwise.org/
Responsible for the review and authorization of all services to the members, utilizing expert knowledge of screening criteria, clinical criteria and research ability if no criteria exists. Uses independent judgment when necessary within scope of practice, including responsibility for medical management audits. Participates in the medical management of members in assigned product lines, including case specific and disease management programs, including catastrophic cases. Works with the PCP, the member and management to promote the delivery of quality services at the most appropriate and cost-effective setting. Performs as the member advocate with emphasis on education regarding managed care, disease management and PCP treatment plans. Monitors member’s utilization patterns for identification of high risk, and under and over use of services. Collaborates with Medical Director and senior management on complex cases and special projects.
RN with a valid unrestrictive license in state of Indiana
Three (3) years clinical nursing experience
Two (2) years experience in Managed Care Utilization Management, Medical Management, Case Management
Five (5) years experience and knowledge of HMO, PPO, TPA, PHO and Managed Care functions including understanding of claims administration, including CPT-4 codes, revenue codes, HCPCS codes, DRGs, etc.
Certified Case Manager (CCM) Certification.
Primary Location: Indiana-Indianapolis-MDwise Inc
Employee Status Regular
Shift Day Job
Job Type Standard
Req ID: 21001081