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 RN 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.
- 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
This position will require work in a downtown Forth Worth Hospital 3 days a week.
The remaining work will be down telephonically from home.
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.
3+ years of managed care and/ or case management experience
Knowledge of utilization management, quality improvement, and discharge planning
Experience working with psychiatric and geriatric patient populations
Bilingual (English/Spanish) language proficiency
Ability to problem solve and identify community resources
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
Utilize critical thinking skills, nursing judgement, and decision making skills
Able 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 380,000+ 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)
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
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: WellMed, Healthcare, Bilingual Spanish, Registered Nurse, RN, CCM, Acute Care, Critical Care, Hospital, LTC, Medicare, Milliman Guidelines, Interqual, Geriatric, Senior, Case Manager, CM, inpatient, Chronic Illness, Dallas, Tyler, Sherman, Waco, Texas, TX