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 Case Manager Inpatient Services - Houston, TX - HOUSTON, Texas, United States

   
Job information
Posted by: UnitedHealth Group 
Hiring entity type: Insurance 
Work authorization: Not Specified for United States
Position type: Direct Hire, Full-Time 
Compensation: ******
Benefits: See below
Relocation: Not specified 
Position functions: Nursing - Case Management
Nursing - Clinic RN
Nursing - Other
Nursing - Staff RN
 
Travel: Unspecified 
Accept candidates: from anywhere 
Languages: English - Fluent
Spanish - Fluent
 
Minimum education: See below 
Minimum years experience: See below 
Resumes accepted in: English
Cover letter: No cover letter requested
Job code: 844394 / Latpro-3700331 
Date posted: Aug-20-2019
State, Zip: Texas, 77001

Description

The Case Manager -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 integrated care team conferences to review clinical assessments, update care plans, identify members at risk for readmission and to finalize discharge plans.

Primary Responsibilities:

  • 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
  • Provides constructive information to minimize problems and increase customer satisfaction
  • Seeks ways to improve job efficiency and makes appropriate suggestions following the appropriate chain of command
  • 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
  • Enters timely and accurate data into designated care management applications as needed to communicate patient needs and maintains audit scores of 90% or better on a monthly/quarterly basis
  • Adheres to organizational and departmental policies and procedures and credentialed compliance
  • Takes on-call assignment as directed
  • Attends and participates in integrated care team meetings as directed
  • Solves problems by gathering and /or reviewing facts and selecting the best solution from identified alternatives
  • Makes decisions based on prior practice or policy, with some interpretation
  • Applies 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
  • With the assistance of the Managed Care/UM teams, guides physicians in their awareness of preferred contracts and providers and facilities
  • Refers cases to Medical Director as appropriate for review or requests not meeting criteria or for complex case situations
  • Participates in the development of appropriate QI processes, establishing and monitoring indicators
  • 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
  • Performs all other related duties as assigned

This position will be located out of our office in NW Houston (I-10 Beltway area) and will require travel approximately 20% of the time to inpatient facilities in the Houston area.

There is potential to transition into a telecommute role once training is completed and strong performance is maintained (approximately 6 months).

Classroom training is 3 to 4 weeks in the office and will also require travel to Dallas to complete the job shadow portion of the training for approximately 3 weeks (travel home on weekends)


There will be 1 week of rotating on-call required (rotation will be approximately every 6 to 8 weeks with on-call differential pay provided)



Required Qualifications:

  • 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 + years of experience
  • Current, unrestricted RN license required, specific to the state of employment
  • 2+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
  • 1+ years of managed care and/ or case management experience
  • Knowledge of utilization management, quality improvement, discharge planning, and cost management
  • Must maintain a valid and current driver’s license
  • 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
  • Proficient with Microsoft Office applications including Word, Excel, and Power Point
  • Independent problem identification/resolution and decision making skills
  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously
  • 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
  • Case Management Certification (CCM)

Physical & Mental Requirements:

  • Ability to lift up to 50 pounds
  • Ability to push or pull heavy objects using up to 25 pounds of force
  • Ability to sit for extended periods of time
  • Ability to stand for extended periods of time
  • Ability to use fine motor skills to operate office equipment and/or machinery
  • Ability to properly drive and operate a company vehicle
  • Ability to receive and comprehend instructions verbally and/or in writing
  • Ability to use logical reasoning for simple and complex problem solving

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 350,000+ 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)

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Case Manager, Medicare, Inpatient, CCM, UM, Utilization Management, Senior, Geriatric, care plan, Houston, TX, care management , transition of care



Requirements

Please see job description.

 

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