RN Case Manager, Inpatient Services – Remote from Texas

WellMed, part of the Optum family of businesses, is seeking a RN Case Manager, Inpatient Services to join our team in Texas. 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. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. 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 I- 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 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 Texas, 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 prior 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

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we’re making health care work better for everyone.

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+ years of experience
• Current, unrestricted RN license specific to the state of employment
• 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
• Proven ability to read, analyze and interpret information in medical records, health plan documents and financial reports
• Proven ability to solve practical problems and deal with a variety of variables
• Proven planning, organizing, conflict resolution, negotiating and interpersonal skills
• Proven independent problem identification/resolution and decision making skills
• Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously
• Ability to maintain a valid and current driver’s license
• Ability to frequently move or be in a stationary position for prolonged periods

Preferred Qualifications:

• Case Management Certification (CCM)
• Experience working with psychiatric and geriatric patient populations
• Bilingual (English/Spanish) language proficiency

Physical & Mental Requirement:

• Ability to properly drive and operate a company vehicle

*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 employer 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.