RN (SCP) Case Manager WellMed

UnitedHealth Group•Corpus Christi, TX

About The Position

Explore opportunities with WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will be part of a team who shares your passion for helping people achieve improved health outcomes. Explore rewarding opportunities for physicians, clinical staff and non-patient-facing roles. Join us and discover the meaning behind Caring. Connecting. Growing together. WellMed provides concierge - level medical care and service for seniors, delivered by physicians and clinic staff that understand and care about the patient’s health. WellMed’s proactive approach focuses on prevention and the complete coordination of care for patients. WellMed is now part of the Optum division under the greater UnitedHealth Group umbrella. The Specialized Clinical Programs (SCP) Case Manager may perform telephonic and/or face-to-face assessments including ongoing re-assessment, case planning, service coordination and monitoring of the services that eligible members with special needs receive. Collaborates with the member and other health care providers to facilitate member access to health and social services, foster adherence to efficient and cost-effective medical treatment regimens which enhance member’s health and well-being. Facilitates a proactive partnership with members to enhance and personalize management of health-related needs. Conducts comprehensive assessment of needs, continuous care plan development, coordination and evaluation of member’s services leading to the goal of equipping and empowering members and caregivers to easily access resources and adopt healthy lifestyles that will increase their ability to remain in the most appropriate care setting. Also responsible for providing health education, coaching and treatment decision support for members. Participates in Interdisciplinary Team conferences (IDT) to review care plan and member progress on identified goals and interventions. The SCP Case Manager will work in partnership with an assigned Care Navigator.

Requirements

Current, unrestricted RN license required, specific to the state of employment including ability to obtain additional state licenses as directed
5+ years of managed care and/or care management experience
5+ years of clinical experience
Experience with CMS and NCQA requirements for Special Needs Programs
Experience carrying caseload of members
Proficient experience in Medicare and Medicaid population
Knowledge of managed care, medical terminology
Proficiency in Microsoft Office products including Access, Excel, Word, PowerPoint and Outlook
Skills in planning, organizing, conflict resolution, negotiation, critical thinking and interpersonal skills to work with autonomy
Proven excellent verbal and written skills
Proven ability to work independently in accomplishing assignments, program goals and objectives
This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor's diagnosis of disease

Nice To Haves

Certified Case Manager (CCM)
10+ years of clinical experience
5+ years of case management experience - telephonic and/or face-to-face

Responsibilities

Ability to assess a complex population and interpret member needs and requirement
Perform individual health risk questionnaires assists with individualized care plan design, documentation and implementation of care plan activity, transitions of care coordination, and evaluation of outcomes
Perform initial review of member’s health records and current health status (e.g., health risk scores) to identify health risk and determine next steps
Perform medication reconciliation
Receive information from members about specific symptoms and answer questions
Identifies the targeted high-risk population, and perform risk stratification
Evaluate member data throughout the assessment process to identify inconsistencies and adherence to Evidence Based Guidelines
Work to develop identified individualized interventions for members in care management
Utilize Motivational Interviewing techniques to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy
Utilizes critical thinking skills to solve complex problems and/or conduct complex analyses
Identify and prioritize gaps to develop plan of care to empower members to meet identified goals
Collaborate with members to set their own goals and align care activities with those goals
Monitor progress of goals, adjust care needs accordingly
Provide treatment recommendations and ongoing monitoring and evaluation of members
Make follow-up calls to ensure members receive the necessary services, resources and care plan created with their nurse
Assure appropriate and complete data entry of all documentation per guidelines
Establish effective collaboration, communication and coordination among all responsible parties of a member’s multidisciplinary health care team
Collaborate with member’s primary care physician and other providers/specialists of any potential problems as they become evident
Ensure members receive the proper level of care via coordination, assessment and interpretation of needs and requirements. Provide specific disease self-management education to members face-to-face and telephonically
Coaches, provides education on disease processes, obtain feedback, and guide members on interventions to improve health outcomes
Responsible for meeting CMS, NCQA, and all other regulatory compliance requirements for CMS Special Needs Program (SNP) Model of Care
Adheres to quality standards, HIPAA, confidentiality, company policies, procedures and reporting requirements
Actively participates in quality assessment/performance improvement program
Works with minimal guidance; seeking guidance on only the most complex tasks
Performs all other related duties as assigned