RN Case Manager High Risk Telecommute West Texas - Case Management

Company: UnitedHealth Group Inc
Location: Abilene
Posted on: November 26, 2022

Job Description:

RN Case Manager High Risk Telecommute West TexasDo 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 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

If you are located in Within the West TX Area, you will have the flexibility to work remotely* as you take on some tough challenges.

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


* Problem solving by gathering and /or reviewing facts and selecting the best solution from identified alternatives. Decision-making is usually based on 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
* 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

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.

Required Qualifications:

* Education:
* 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 RN license required, specific to the state of employment
* Must maintain a valid and current driver's license
* 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
* Proficient with Microsoft Office applications including Word, Excel, and Power Point
* Ability to read, analyze and interpret information in medical records, health plan documents and financial reports

Preferred Qualifications:

* Case Management Certification (CCM)
* Experience working with psychiatric and geriatric patient populations
* Bilingual (English/Spanish) language proficiency
* 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
* Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously
* Frequently required to stand, walk or sit for prolonged periods
* 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

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 receive and comprehend instructions verbally and/or in writing
* Ability to use logical reasoning for simple and complex problem solving

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.

* All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

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 Inc, Abilene , RN Case Manager High Risk Telecommute West Texas - Case Management, Executive , Abilene, Texas