Mercy Health

  • Case Manager II

    Requisition ID
    Rehabilitation/Therapy Services
    Position Type
    Full Time
    Aco 1
  • Overview

    Job Template Header


    We’re a Little Different


    Our mission is clear. We bring to life a healing ministry through our compassionate care and exceptional service.


    At Mercy, you’ll feel our supportive community every step of your day, especially the tough ones. We’re a team and love working that way. We have opportunities for nurses who are inspired to pioneer new models of care and want to transform the healthcare experience. Work with advanced technology and innovative procedures. Be state of the art, and never stop exploring. We’re expanding to help our communities grow, offering an exceptional opportunity to join our team.



    In collaboration with the interdisciplinary team, case managers are responsible for assessing, planning, implementing, monitoring, and evaluating options and services required to meet an individuals health needs. Case managers are responsible for facilitating the timely and appropriate transition of patients along the healthcare continuum. The focus of their efforts is to access quality care for patients by collaborating with payers and providers in developing, implementing and evaluating quality, cost-effective treatment options delivered in the most appropriate setting. Educating members and providers to options in the managed care arena is also part of the case managers daily duties. The case managers endeavor to avoid duplication and fragmentation of care that can frustrate all parties involved-patients, payers, and providers. Identifying and helping bridge the gaps and barriers in the health system and community resources is also part of the case managers focus. Health System Disease Management initiatives are fully integrated into the Case Management position. Specific Case Management interventions are performed for the purpose of meeting Medical Management Objectives. Areas of Assignment / Specialty: Full Continuum Case Manager The Health Plans Medical Management health plan based case managers are assigned to all aspects of medical management including identification and referral to disease management programs, across the continuum for the health plan member. This includes out patient medical management as well as inpatient admission, concurrent review, and coordination of care related to inpatient admissions particularly at out of network facilities. Analysis of common treatment options and patterns of care for process improvements is also part of the health plan based case managers assignment. They are instrumental in pre-admission, utilization management, discharge planning, post hospitalization follow up and coordination of appropriate medical services for health plan or other contracted patients. All case managers perform duties and responsibilities in a manner consistent with our mission, values, and Mercy Service Standards.



    Selects patients for full continuum case management according to departmental policies & procedures. Collects thorough and objective information about the physical, psychosocial, environmental, and financial needs and resources of individual patients. Develops specific and realistic objectives, goals, and action plan tailored to the individual needs of each patient. Implements specific interventions focused on the specific goals established for the individual. Facilitates access to necessary resources to accomplish patient-centered goals.

    Analyzes sufficient information from all relevant resources to determine effectiveness of the case management plan. Modifies components or the entirety of the case management plan dependent upon its effectiveness in reaching desired outcomes.

    Demonstrates functional knowledge of the legal and ethical issues pertaining to confidentiality of patient information. Demonstrates functional knowledge of legal and ethical issues related to case management and managed care.

    Advocates for the individuals health care needs with emphasis on responsible health practices, self care and patient safety. Collaborates with patient, family, physicians, payer representatives and other members of the healthcare team.

    Demonstrates functional understanding of the requirements for prior approval by payers. Develops and maintains rapport with a broad network of providers. Negotiates contracts with appropriate providers to attain necessary resources for individual patients. Proposes and negotiates individual contractual agreements with providers as needed to meet patient care needs.

    Builds bridges to correct and/or adapt to gaps and barriers in treatment options with creative care planning. Reports and participates in resolution of identified gaps and barriers in the health system.

    Establishes goals that are measurable, based on the assessment of the consumers' needs, includes a timeline for achievement, and are reviewed and updated as necessary.

    Evaluates the quality of necessary medical services and evaluates the cost in relation to the benefits of care options. Demonstrates functional knowledge of established communication channels with health plans.

    Coordinates care provided throughout the full continuum of care, including but not limited to ambulatory care, acute inpatient care, skilled care, home health care, rehabilitative care, and community programs. Supports activities designed to bring about quality care, education of the patient/family/caregiver, preventative care, timely discharge, and reduction of readmissions, and promotes patient safety.

    Reports quantifiable impact, quality of care, and quality of life improvements as measured against the case management goals.

    Documents case management activities timely and according to departmental policies and procedures, NCQA, URAC and Case Management Society of America Standards.

    Administers resource controls per terms, limitations, and exclusions of the health plan benefits. Proactively arranges patient care utilizing controls, assessing the appropriateness of proposed services, individualizing treatment plans, and avoiding more costly interventions later.

    Uniformly applies pre-established review criteria for precertification of services and initial and concurrent review of consumers in various levels of care.

    Performs On Call duties as required to support members receiving Health Plans Medical Management services and Nurse On Call services to ensure quality of care and patient safety.

    Prioritizes and organizes tasks effectively and efficiently. Works within established lines of authority. Accepts responsibility and is accountable for the Case Management plan and process. Provides input on the performance of support staff to Health Plans managers.

    Performs other duties as assigned.

    Meets Health System attendance standards.

    Wears clothing and health system badge consistent with dress code and attends to personal hygiene to maintain a clean, well-groomed appearance.



    Position Qualifications:

    • We require a nursing degree from an accredited school.
    • You’ll also need a current RN license in our state.
    • Basic life support training should be completed in 90 days with advanced training required at certain intervals.

    Minimum of 5 years diversified direct clinical experience in nursing.

    Certifications: CCM certification preferred

    Preferred Education: BSN

    Preferred Other: Familiarity with computer uses and applications is recommended.


    We’ll Support You at Work and Home


    Getting respect doesn’t come easy in healthcare. Modern Healthcare Magazine named us as a “top 100 places to work.” We go out of our way to help people feel welcomed. We offer day-one comprehensive health, vision and dental coverage, PTO, tuition reimbursement and employer-matched retirement funds to benefit-eligible co-workers, including those working 48 hours or more per pay period!



    What Makes a Good Match for Mercy


    Compassion and professionalism go hand-in-hand with us. Having a positive outlook and a strong sense of advocacy is in perfect step with our mission and vision. We’re also collaborative and are not afraid to do a little extra to deliver excellent care-that’s just part of our commitment. If that sounds like a fit for you as well, we encourage you to apply.



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