The Case Manager 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. 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 a. 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. a. 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. a. 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 Performs all other related duties as assigned
Required Qualifications:Education required: 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 or more years of experienceCurrent, unrestricted RN license required, specific to the state of employment Five or more years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions Two or more years of managed care and/ or case management experience Knowledge of utilization management, quality improvement, discharge planning, and cost management Must maintain a valid and current driver's license Ability to read, analyze and interpret information in medical records, health plan documents and financial reports Ability to solve practical problems and deal with a variety of variables Possess planning, organizing, conflict resolution, negotiating and interpersonal skills Proficient with Microsoft Office applications Independent problem identification/resolution and decision making skills Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously Frequently required to stand, walk or sit for prolonged periods Case Management Certification (CCM) or ability to obtain CCM within 6 months after the first year of employmentPreferred Education, Experience & SkillsExperience working with psychiatric and geriatric patient populations Bilingual (English/Spanish) language proficiencyCareers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 90,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.SM 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.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.
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.