Nurse Case Manager

Company: UnitedHealth Group
Location: Mesquite
Posted on: March 15, 2023

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