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 Inpatient RN Case Manager 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. Participates in integrated care team conferences to review clinical assessments, update care plans, identify members at risk for readmission and to finalize discharge plans.
Collaborates effectively with integrated care team (ICT) to establish an individualized plan of care for members; the interdisciplinary care team develops interventions to assist the member in meeting short and long term plan of care goals
Serves as the clinical liaison with hospital, clinical and administrative staff as well as provides expertise for clinical authorizations for inpatient care. based on utilized evidenced-based criteria
Performs concurrent and retrospective onsite or telephonic clinical reviews at the designated network or out of network facilities; documents medical necessity and appropriate level of care utilizing national recognized clinical guidelines
Interacts and effectively communicates with facility staff, members and their families and/or designated representative to assess discharge needs and formulate discharge plan and provide health plan benefit information
Stratifies and/or validates patient level of risk and communicates during transition process with the Integrated Care Team
Provide assessments of physical, psycho-social and transition needs in settings not limited to the PCP office, hospital, or member’s home; develops interventions and processes to assist the member in meeting short and long term plan of care goals
Manages assigned case load in an efficient and effective manner utilizing time management skills to facilitate the total work process directly monitoring assigned members
Demonstrates knowledge of utilization management and care coordination processes and current standards of care as a foundation for transition planning activities
Confers with physician advisors on a regular basis regarding inpatient cases and participates in department case rounds. Plans member transitions, with providers, patient and family
Problem solving by gathering and /or reviewing facts and selecting the best solution from identified alternatives; decision-making is usually based on prior practice or policy, with some interpretation; must apply individual reasoning to the solution of problems, devising or modifying processes and writing procedures as necessary
Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms
Refers cases to Medical Director as appropriate for review or requests not meeting criteria or for complex case situations
Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations
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.
Bachelor’s degree in Nursing, or
Associate’s degree in Nursing and Bachelor’s degree in related field, or
Associate’s degree in Nursing combined with 4 or more years of experience
Current, unrestricted Texas RN license or compact state RN license
Case Management Certification (CCM) or ability to obtain CCM within one year of employment
5+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
2+ years of managed care and/or case management experience
Knowledge of utilization management, quality improvement, discharge planning, and cost management
Proficient with Microsoft Office applications including Word, Excel, and Power Point
Frequently required to stand, walk or sit for prolonged periods
Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area
This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor’s diagnosis of disease
Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
Experience working with psychiatric and geriatric patient populations
Bilingual (English/Spanish) language proficiency
Ability to read, analyze and interpret information in medical records, health plan documents and financial reports
Ability to solve practical problems and deal with a variety of variables
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
Independent problem identification/resolution and decision making skills
Able to prioritize, plan, and handle multiple tasks/demands simultaneously
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment
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.
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.