RN Case Manager – Hospital Utilization and Transitions of Care

UnitedHealth Group•Las Vegas, NV

4d•$35 - $63•Onsite

About The Position

Optum NV is seeking a Case Manager RN to join our team in Las Vegas, NV. Optum is a clinician-led care organization that is changing the way clinicians work and live. We are currently offering a $10,000 sign on bonus for external candidates! 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. Daily operational responsibilities include utilization management, discharge planning, referral facilitation and/or collaboration with hospital- based case managers/physicians to move patients to appropriate level of care. Provide Care interdisciplinary team communication about the hospital stays. This is an on-sight hospital- based function requiring the Case Manager RN to travel to 1-2 hospitals daily, work in collaboration with the hospitalist to improve outcomes with Observation stay, long discharge plans and prevention of readmission. Primary responsibility for case management includes discharge planning, improved transitions of care, and utilization management of long length hospitalized health plan members. Ensure members receive quality medical care in the most appropriate setting. Performs the following on a daily basis; 1) performs patient assessment of all major domains using evidence based criteria (physical, functional, financial and psychosocial); 2) develop individualized discharge plans that involve provider, patient and caregiver goals for successful transitions of care; 3) implement discharge plan involving health care resources across the continuum; and 4) monitor and report variances that may challenge timely quality care.

Requirements

High School diploma and/or equivalent
Active unrestricted Nevada RN license
Ability to obtain CCM certification within two years of employment
2+ years of varied clinical experience in a hospital or clinical setting with an emphasis on case management
Experience in a managed care organization
Knowledge of utilization management in a managed care environment
Independent case management knowledge and skills to formulate plans of care without direct supervision
Understanding of spectrum of alternative delivery systems
Ability to use computer-based programs and applications
Demonstrated initiative toward problem solving without direct supervision
Proven solid organizational, written, oral computer skills
Proven excellent problem-solving skills
Proven ability to negotiate with professionals, patients, and caregivers
Critical Thinking: Proven ability to integrate guidelines/tools to negotiate most effective plan of care. Formulate plans that incorporate the health plan benefits, community services and patient self-direction
Valid Nevada driver’s license and maintain personal auto insurance coverage

Nice To Haves

Bachelor’s degree
Knowledge of Interqual or Milliman guidelines
Recent Emergency Room hospital care or hospital discharge planning
Certification in Case Management (CCM) or equivalent Professional Certification (ACM)

Responsibilities

Assess, plan and implement care strategies that are individualized by patients and directed toward the most appropriate, lease restrictive level of care
Utilize both company and community-based resources to establish a safe and effective case management plan for hospitalized members
Collaborate with patient, family and health care providers to develop an individualized plan of care that encompasses both acute care episode and post hospital discharge plan
Communicate with all stakeholders the required health related information to ensure quality coordinated care and services are provided expeditiously to all hospitalized members
Advocate for patients and families as needed to ensure the patient’s needs and choices are fully represented and supported by the health care team
Utilize approved clinical criteria to assess and determine appropriate level of care for hospitalized members
Understand insurance products, benefits, coverage limitations, insurance and governmental regulations as it applies to the health plan
Understand role and how it affects utilization management benchmarks and quality outcomes
Coordinate hand-off of care to primary care provider
Participation in departmental projects assigned by Director or Manager