RN - Sr. Clinical Case Manager

UnitedHealth Group•Albuquerque, NM

1d•$72,800 - $130,000•Onsite

About The Position

Positions in this function facilitates a team approach to ensure cost-effective delivery of quality care and services based on medical conditions and social determinants. Collaborates with members, providers, and other resources to assess, plan, implement, coordinate, monitor and evaluate options and services required to meet an individual’s healthcare needs. Promotes member’s goals for self management, facilitates effective health care system navigation, reduces gaps in care, and provides support and community resources as needed. Ensures compliance to contractual and service standards as identified by relevant health insurance plans. Adheres to policies, procedures and regulations to ensure compliance and patient safety.

Requirements

Associates Degree in Nursing
Valid NM RN License or valid multi-state compact license
Current BLS Certification
3+ years of job-related experience in a healthcare environment
Excellent communication, interpersonal, organization and customer service skills
Self-motivated, attention to detail
Ability to multi-task and work under pressure
Demonstrates knowledge of computer functionality and software applications (e.g., navigating systems, troubleshooting, electronic charting, accessing intranet and record management databases)
Demonstrate knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, commercial) or regulatory bodies (e.g.,NCQA)
Demonstrate understanding of relevant health care benefit plans

Nice To Haves

Bachelor’s degree or higher in healthcare related field
Case Management Certification
3+ years of experience providing case management and/or utilization review functions within health plan or integrated system

Responsibilities

Role embedded within the primary care clinic, working directly with both clinical and non-clinical staff
Conducts clinical evaluation of members per regulated timelines, determining who may qualify for complex case management based on clinical judgment, changes in member's health, social determinants, and gaps in care
Creates and implements a case management plan in collaboration with the member, caregiver(s), provider(s), and/or other appropriate healthcare professionals to address the patient’s needs and goals
Performs ongoing updates of the care plan to evaluate effectiveness, and to document barriers, interventions, and goal achievement
Partners with primary providers or multidisciplinary team members to align or integrate goals to plan of care
Supports longitudinal care of the patient with chronic care conditions
Supports transition of care from inpatient to outpatient setting
Completes home, facility, clinic and telephonic visits for member engagement and enrollment
Uses motivational interviewing to evaluate, educate, support, and motivate change during member contacts
Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed
Achieves Quality Measures outcomes via reduction in HEDIS Gaps in Care
Performs accurate and timely documentation in the electronic medical record
May perform clinical tasks within their scope of practice
Ensures compliance with quality metrics specific to health plan delegation and accrediting body requirements
Conducts self and peer audits
Maintains caseload per defined medical management department standards
Sustains productivity and audit requirements per medical management department standards
Demonstrates ability to work independently and implement innovative approaches to complex member situations
Sought out as expert and serves as leader/mentor to other members of medical management team
Determines need for continued member management, creates care plan and facilitates transition to medical management programs
Serves as facilitator and resource for other members of the Medical Group clinical team
Attends departmental meetings and provides constructive recommendations for process improvement
Performs other duties as assigned