At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

                        

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

                                    

Job TitleEmployee Health Plan Case Manager

                        

LocationCleveland

                    

FacilityRemote Location

                     

DepartmentClinical Integration Health Plan Management-Finance

                      

Job CodeT98257

                     

ShiftDays

                       

Schedule8:00am-4:30pm

                       

Job Summary

                         

Job Details

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 nursingOhio licensure as a Registered Nurse (RN)Additional Multistate License (MSL) or eligible for MSL to be obtained within 90 days of hireBasic Life Support (BLS) through the American Heart Association (AHA)Three years of relevant clinic experienceKnowledge of medical terminology, medical records coding standards, billing practices and Care Guidelines, Medical Necessity Criteria and/or Utilization management criteria setProficiency 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 eligibilityKnowledge 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 findingsThree years of critical care or high acuity experience in ICU or EDProficiency in EPICExperience with Utilization ReviewExpertise 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.

                       

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. All offers of employment are follwed by testing for controlled substances and nicotine. All new caregivers must clear a nicotine test within their 90-day new hire period. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after one year.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

Please review the Equal Employment Opportunity poster. 

                  

Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities