Nurse Case Manager
Company: UnitedHealth Group
Location: Mesquite
Posted on: March 15, 2023
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Job Description:
Do you have compassion and a passion to help others?
Transforming healthcare and millions of lives as a result starts
with the values you embrace and the passion you bring to achieve
your life's best work.(sm)
The Case Manager II - Inpatient Services performs onsite review or
telephonic clinical review of inpatient admissions in an acute
hospital, rehabilitation facility, LTAC or skilled nursing
facility. Actively implements a plan of care utilizing approved
clinical guidelines to transition and provide continuity of care
for members to an appropriate lower level of care in collaboration
with the hospitals/physician team, acute or skilled facility staff,
ambulatory care team, and the member and/or family/caregiver. The
case manager is responsible for coordinating the care from
admission through discharge. The Case Manager participates in
Patient Care Conferences to review clinical status, update/finalize
transition discharge needs, and identify members at risk for
readmission.
Primary Responsibilities:
--- Independently collaborates effectively with Interdisciplinary
care team (ICT) to establish an individualized transition plan for
members
--- Independently serves as the clinical liaison with hospital,
clinical and administrative staff as well as performs a review for
clinical authorizations for inpatient care utilizing
evidenced-based criteria within our documentation system
--- Performs expedited, standard, concurrent, and retrospective
onsite or telephonic clinical reviews at in network and/or out of
network facilities. The Case Manager documents medical necessity
and appropriate level of care utilizing national recognized
clinical guidelines for all authorizations
--- Interacts and effectively communicates with facility staff,
members and their families and/or designated representative to
assess discharge needs, formulate discharge plan and provide health
plan benefit information
--- Identifies member's level of risk by utilizing the Population
Stratification tools and communicates during transition process the
member's transition discharge plan with the ICT
--- Conducts a transition discharge assessment onsite and/or
telephonically to identify member needs at time of transition to a
lower level of care
--- Manages assigned case load in an efficient and effective manner
utilizing time management skills
--- Demonstrates exemplary knowledge of utilization management and
care coordination processes as a foundation for transition planning
activities
--- Independently confers with UM Medical Directors and/ or Market
Medical Directors on a regular basis regarding inpatient cases and
participates in department huddles
--- Enters timely and accurate documentation into designated care
management applications to comply with documentation requirements
and achieve audit scores of 90% or better on a monthly basis
--- Adheres to organizational and departmental policies and
procedures
--- Takes on-call assignment as directed
--- Maintain current licensure to work in State of employment and
maintain hospital credentialing as indicated
--- Decision-making is based on regulatory requirements, policy and
procedures and current clinical guidelines
--- Maintains current knowledge of health plan benefits and
provider network including inclusions and exclusions in contract
terms
--- Refers cases to UM Medical Director as appropriate for review
for cases not meeting medical necessity criteria or for complex
case situations
--- Monitors for any quality concerns regarding member care and
reports as per policy and procedure
--- Performs all other related duties as assigned
You'll be rewarded and recognized for your performance in an
environment that will challenge you and give you clear direction on
what it takes to succeed in your role as well as provide
development for other roles you may be interested in.
This is a hybrid role. You will be able to telecommute and also
make visits to hospitals in the Sherman, Mesquite and Plano area
approximately 25% of the time. Hours are Monday through Friday 8am
to 5pm.
Required Qualifications:
--- Bachelor's degree in Nursing and/or, Associate's degree in
Nursing combined with 2+ years of experience
--- Current, unrestricted RN license, specific to the state of
employment
--- Case Management Certification (CCM) or ability to obtain CCM
within 2+ years after the first year of employment
--- 3+ years of managed care and/ or case management experience
--- 2+ years of diverse clinical experience in caring for the
acutely ill patients with multiple disease conditions
--- Knowledge of utilization management, quality improvement, and
discharge planning
--- Knowledgeable in Microsoft Office applications including
Outlook, Word, and Excel
--- Frequently required to stand, walk or sit for prolonged
periods
Preferred Qualifications:
--- Experience working with psychiatric and geriatric patient
populations
--- Bilingual (English/Spanish) language proficiency
--- Demonstrated ability to read, analyze and interpret information
in medical records, and health plan documents
--- Demonstrated ability to problem solve and identify community
resources
--- Demonstrated planning, organizing, conflict resolution,
negotiating and interpersonal skills
--- Demonstrated ability to utilize critical thinking skills,
nursing judgement, and decision making skills
--- Demonstrated ability to prioritize, plan, and handle multiple
tasks/demands simultaneously
Careers with WellMed. Our focus is simple. We're innovators in
preventative health care, striving to change the face of health
care for seniors. We're impacting 550,000+ lives, primarily
Medicare eligible seniors in Texas and Florida, through primary and
multi-specialty clinics, and contracted medical management
services. We've joined Optum, part of the UnitedHealth Group family
of companies, and our mission is to help the sick become well and
to help patients understand and control their health in a lifelong
effort at wellness. Our providers and staff are selected for their
dedication and focus on preventative, proactive care. For you, that
means one incredible team and a singular opportunity to do your
life's best work.(sm)
WellMed was founded in 1990 with a vision of being a physician-led
company that could change the face of healthcare delivery for
seniors. Through the WellMed Care Model, we specialize in helping
our patients stay healthy by providing the care they need from
doctors who care about them. We partner with multiple Medicare
Advantage health plans in Texas and Florida and look forward to
continuing growth.
At UnitedHealth Group, our mission is to help people live healthier
lives and make the health system work better for everyone. We
believe everyone-of every race, gender, sexuality, age, location
and income-deserves the opportunity to live their healthiest life.
Today, however, there are still far too many barriers to good
health which are disproportionately experienced by people of color,
historically marginalized groups and those with lower incomes. We
are committed to mitigating our impact on the environment and
enabling and delivering equitable care that addresses health
disparities and improves health outcomes - an enterprise priority
reflected in our mission.
Diversity creates a healthier atmosphere: OptumCare is an Equal
Employment Opportunity/Affirmative Action employers and all
qualified applicants will receive consideration for employment
without regard to race, color, religion, sex, age, national origin,
protected veteran status, disability status, sexual orientation,
gender identity or expression, marital status, genetic information,
or any other characteristic protected by law.
OptumCare is a drug-free workplace. Candidates are required to pass
a drug test before beginning employment.
Keywords: UnitedHealth Group, Mesquite , Nurse Case Manager, Executive , Mesquite, Texas
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