Case Manager RN WellMed Parkdale

UnitedHealth Group•Corpus Christi, TX

4h•$60,200 - $107,400•Onsite

About The Position

WellMed, part of the Optum family of businesses, is seeking a Case Manager RN to join our team in Corpus Christi, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live. As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together. The 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.

Requirements

Bachelor’s degree in Nursing and/or, Associate’s degree in Nursing combined with 4+ years of experience above the required years of experience
Current, unrestricted RN license specific to the state of employment
Case Management Certification (CCM) or ability to obtain CCM within 12 months after the first year of employment.
4+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
3+ years of managed care and/ /or case management experience
Knowledge of utilization management, quality improvement, and discharge planning
Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel
Proven ability to read, analyze and interpret information in medical records, and health plan documents
Proven ability to problem solve and identify community resources
Proven planning, organizing, conflict resolution, negotiating and interpersonal skills
Proven ability to utilize critical thinking skills, nursing judgement, and decision making skills
Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously
Proven ability to be in a stationary position or move for prolonged periods
Reliable transportation and Case Manager is responsible for maintaining an active driver’s license

Nice To Haves

Experience working with psychiatric and geriatric patient populations
Bilingual (English/Spanish) language proficiency

Responsibilities

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%25 or better on a monthly basis
Adheres to organizational and departmental policies and procedures
Takes on-call assignment as directed
The Case Manager will also 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