Join the Cleveland Clinic team where you will work alongside passionate caregivers and provide patient-first healthcare. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world. As an EHP Case Manager, you will manage cost-effective, high-quality patient outcomes by coordinating care and collaborating with providers, staff and a diverse client population. This role involves ongoing assessment, education and support to guide clients through their care journey, while ensuring appropriate use of network services and resources. You will work closely with a multidisciplinary team to monitor progress, anticipate needs and help clients access the clinical services needed to maximize their health benefits. **Caregivers in this role will work Monday through Friday from 8:00am to 4:30pm. No weekend requirements. This is a remote position with occasional on-site requirements and you are required to live in the Cleveland OH area.** A caregiver who excels in this role will: + Manage cost-effective, quality patient outcomes by collaborating and coordinating with staff, providers and a diverse population of patients/members to provide guidance, education and support to assigned patients. + Collaborate and consult with a multidisciplinary team regarding a patient's progress and perform continuous assessments as well as provide evaluations to monitor client's progress towards established goals. + Anticipate client's needs and assist with planning and obtaining required services to maximize benefit plan. + Recommend resource utilization. + Utilize analytical abilities to gather data as well as use clinical judgement to apply predetermined criteria. + Apply medical necessity guidelines accurately to monitor appropriateness of items requiring prior authorization. + Follow department guidelines on escalation processes to management and refers cases appropriately to the Medical Director. + Document appropriately in Tapestry to provide evidence that the UR process for the referral was followed. + Monitor in-network and out of network utilization of providers and services. + Monitor for potential high dollar costs and redirect when appropriate. + Coordinate transfer of care to in-network facilities for patients admitted to out-of-network facilities. + Contact recently discharged patients via telephone per department protocol and interact with all callers in a professional and courteous manner as well as follow established guidelines and document all interactions via EMR and department systems accurately. + Serve as a liaison between health plan, patient and providers as needed. Minimum qualifications for the ideal future caregiver include: + Graduate from an accredited school of nursing + Ohio licensure as a Registered Nurse (RN) + Additional Multistate License (MSL) or eligible for MSL to be obtained within 90 days of hire + Basic Life Support (BLS) through the American Heart Association (AHA) + Three years of relevant clinic experience + Knowledge of medical terminology, medical records coding standards, billing practices and Care Guidelines, Medical Necessity Criteria and/or Utilization management criteria set + Proficiency in Microsoft Office Preferred qualifications for the ideal future caregiver include: + Bachelor of Science in Nursing (BSN) + Certified Case Manager (CCM) within the first year of eligibility + 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 + Three years of critical care or high acuity experience in ICU or ED + Proficiency in EPIC + Experience with Utilization Review + Expertise with electronic medical records Our caregivers continue to create the best outcomes for our patients across each of our facilities. Click the link and see how we're dedicated to providing what matters most to you: https://jobs.clevelandclinic.org/benefits-2/ **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. **Pay Range** 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. Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities