Description |
This role focuses on using a person centered approach. The nurse assesses plans, coordinates, implements, monitors and evaluates the options and services required to meet an individual’s physical and behavioral health needs using communication and available resources to promote quality, cost-effective outcomes. This individual is responsible for the monitoring and oversight of Care Coordination Organizations (CCO) evaluation and coordination of all health care services provided to a select care population to manage the continuum of care, Quality management, performance reviews, and contract oversight for total care of the enrollees’ health care needs. They will also provide relevant and measurable outcomes to the administration, Management Committees and CCO’s.
Primary Responsibilities Include:
- Review referrals and authorizations following established policies and procedures in accordance with nationally recognized standards.
- Process and manage referrals using online system called WA Health home System, evidence based guidelines and criteria hierarchy from DBHR.
- Co-facilitate a multidisciplinary team when necessary that monitors the coordination of health care services with appropriate agency physicians, facilities, contracted providers, ancillary providers, allied health professionals, and community resources.
- Act as liaison between member, Care Team and MHC Medical Directors.
- Manage the CCO on Coordination of care for beneficiaries of the health home.
- Provide alternative health care services utilizing contracted, community and internal services/programs.
- Participate in patient case review, utilization management meetings and QA/PI as requested.
- Maintain comprehensive and confidential case files.
- Utilize clinical knowledge to apply any/all approved evidence-based practice guidelines and criteria.
- Coordinate with the interdisciplinary care team in making a safe discharge plan and make appropriate new referrals for additional care coordination, such as Case Management, Social Work.
- Correspond with facilities, members and providers for clinical information and details of review request, when warranted, as well as, for the provision of a final determination for a prospective or concurrent medical necessity review
- Maintain confidentiality of all member information and health home business.
- Present as a professional representative of Optum.
- Perform additional duties/tasks as assigned by Supervisors and Manager.
- Maintain and comply with all Optum policies and procedures.
- Attend in-services, training and meetings relating to job tasks as directed and required.
- Regular and consistent attendance.
- Correspond with facilities, members and providers for clinical information and details of review request, when warranted, as well as, for the provision of a final determination for a prospective or concurrent medical necessity review
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Requirements |
- Current, valid and unrestricted RN license in the State of Washington
- Minimum of 3 years of experience working with individuals with chronic conditions required
- Basic level of experience with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environment
- Outstanding critical thinking and customer service skills, problem solving ability, prioritization and organizational skills are required
- Ability to interpret a variety of data, ability to set priorities, define and implement effective workflow and processes.
Preferred assets include:
- BSN or equivalent
- Experience in acute long term care
- Knowledge of person-centered wellness approach
- Experience in managing Health Home benefits
- Prior experience with Evidence Based Practice
- Previous managed care experience
- Prior Case Management and/or Utilization Management experience
OptumHealth is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
OptumHealth helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their health care needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.
At OptumHealth, you will perform within an innovative culture that's focused on transformational change in the health care system. You will leverage your skills across a diverse and multi-faceted business. And you will make contributions that will have an impact that's greater than you've ever imagined.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.
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