This is a casual position (10-15 hours per week - flexible schedule) with a hybrid remote work arrangement in our Sheboygan, WI location.

Prairie States Enterprises, Inc. is a third party administrator, a benefits industry leader, and a trusted advisor to self-insured companies and their employees.  We provide a complete range of medical benefit management services, all performed in-house, and to exacting standards of excellence by our professional staff. 

JOB SUMMARY

The Optimal Health or Disease Management Coach works with a team of Registered Nurses and Certified Health Coaches, to provide telephonic, e-coaching, internal and client consultation for program participants to support workplace and individual chronic disease or condition support.

SUMMARY OF ESSENTIAL JOB FUNCTIONS

• Carry a caseload of clients to provide confidential phone-based health coaching
• Provide telephonic coaching to individuals of contracted companies identified for a defined chronic condition within the coach scope of practice
• Ability to assess coaching participant’s needs and theory of change utilizing a holistic approach with an emphasis on the health condition
• Utilize readiness for change, locus of control assessments and productivity measures to guide care
• Review pertinent medical history, current diagnosis, and pharmaceutical data via information database system as available
• Assist participants in forming solutions and setting realistic goals for improving health risks
• Utilization and referral for appropriate community resources
• Promote self-management practices consistent with National Guidelines and provide education regarding self-care measures
• Document coaching session and goal setting in Acuity System
• Communicate/and or refer to other disciplines at PSE when appropriate
• Adhere to HIPAA standards
• Under direction of VP, Health Services, other duties as assigned including program development and improvement

• Bachelor’s in Nursing, Exercise Science or relevant degree match preferred.
• Certifications in CHES, ACE, or other relevant area(s) a plus.
• Continuing education to support credentials.  If none required, a minimum of four hours per year of continuing education, condition specific.  
• Basic to intermediate level computer skills.
• Computer Skills: Word, Excel, Microsoft Outlook, keyboarding and data entry
• Telephone etiquette
• Must be able to carry on conversations with medical providers, and members to facilitate good understanding by all parties

REQUIRED COMPETENCIES

• Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals.
• Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure.
• Accountability/Results – Achieves and/or exceeds result-based goals that were specific, measurable, and timely.
• Teamwork – Demonstrates teamwork behaviors and makes positive contributions and which support the achievement of department goals.
• Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations in providing exemplary service.
• Professional Growth – Takes ownership of one’s professional growth within one’s current position and to advancement at PSE.

This is sedentary position which requires the individual to sit for long periods of time and the proper positioning/posturing for extensive viewing of computer screens and computer related work is required.  It is encouraged that individuals intermix this sedentary time with periodic movement within one’s office space and/or to other office areas to counteract the sedentary nature of this position.    

• Claim reviews:  Pre-Claim, Concurrent Claim, and Post-Claim Reviews (Retro Reviews) as identified by claims analyst, bill audit staff, or Health Management
• Responsible for UM-RN function of designated groups.
• Reviews and contacts Clinical staff at the Provider for medical information to ensure the completeness of the medical record.  
• Researches Plan language in the Employer Benefit Plan Document, and makes a clinical determination of coverage or no coverage.  
• Coordinates the sending of cases out for medical review if required.
• Responsible for the authorization of services or denial of services based on the Employer Benefit Plan Document. Subsequently also handles all appeals.  
• Assists with maintaining Quick Reference Guide for designated groups
• Stop Loss Reporting: 
  • Notify Case Manager of potential need for CM as appropriate
• Vacation and Overflow coverage for standard Pre-certification and Utilization Management staff
• Assists with writing and updating Policies and or Procedures related to the UM function

• BSN Required; RN current licensure in good standing
• Minimum of 5 years of clinical experience
• Past UM or CM experience in clinical or hospital setting desirable
• Strong competence in the use and understanding of the MCG guidelines for medical necessity
• Strong competence with patient care management systems
• Proficient Computer Skills: Word, Excel, Microsoft Outlook, keyboarding and data entry

• Change Management – Accepts, supports, and executes assignments in conditions of change which support attaining department goals.
• Effective Communication – Demonstrates effective and responsive communications following the appropriate reporting structure. 
• Accountability/Results – Achieves and/or exceeds result based goals that were specific, measurable, and timely.
• Teamwork – Demonstrates teamwork behaviors and makes positive contributions and which support the achievement of department goals.
• Customer Satisfaction – Dedicated to the PSE service model and meets or exceeds PSE customer satisfaction expectations in providing exemplary service.
• Professional Growth – Takes ownership of one’s professional growth within one’s current position and to advancement at PSE.

• Competitive compensation based on experience and a benefit package which includes leave benefits, 401k with match, wellness and exercise membership and more.  
• Opportunity for meaningful career growth within a results-driven company and our company culture is one of ambition, integrity, empowerment, teamwork and a passion for personal and company success.