Case Manager RN WellMed Corpus Christi, TX
Company: Optum
Location: Corpus Christi
Posted on: May 3, 2024
Job Description:
Opportunities at WellMed, part of the Optum family of
businesses. We believe all patients are entitled to the highest
level of medical care. Here, you will join a team who shares your
passion for helping people achieve better health. With
opportunities for physicians, clinical staff and non-patient-facing
roles, you can make a difference with us as you discover the
meaning behind 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.
This a hybrid role in Corpus Christi, TX office and work from
home.
Primary 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% 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 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:
- 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
- RN licensure in TX
- 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
- Reliable transportation and Case Manager is responsible for
maintaining an active driver's license
- 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
- Ability to frequently stand, walk or sit for prolonged
periods
- 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 Preferred Qualifications:
- 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 At
UnitedHealth Group, our mission is to help people live healthier
lives and make the health system work better for everyone. We
believe everyone-of every race, gender, sexuality, age, location
and income-deserves the opportunity to live their healthiest life.
Today, however, there are still far too many barriers to good
health which are disproportionately experienced by people of color,
historically marginalized groups and those with lower incomes. We
are committed to mitigating our impact on the environment and
enabling and delivering equitable care that addresses health
disparities and improves health outcomes - an enterprise priority
reflected in our mission.
Diversity creates a healthier atmosphere: UnitedHealth Group 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.
UnitedHealth Group is a drug-free workplace. Candidates are
required to pass a drug test before beginning employment.
Keywords: Optum, Victoria , Case Manager RN WellMed Corpus Christi, TX, Executive , Corpus Christi, Texas
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