UnitedHealth Group Case Manager (High Risk IP) RN - Jacksonville, FL in Jacksonville, Florida
We're making a strong connection between exceptional patient care and outstanding career opportunities. The result is a culture of performance that's driving the health care industry forward. As a Telephone Case Manager RN with UnitedHealth Group, you'll support a diverse member population with education, advocacy and connections to the resources they need to feel better and get well. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Apply today!
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
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
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.
Bachelor's degree in Nursing, or associate degree in Nursing and bachelor's degree in related field, or associate degree in Nursing combined with 4 or more years of experience
Current, unrestricted RN license required, specific to the state of employment
5+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
2+ 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 including Word, Excel, and Power Point
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 6months after the first year of employment
Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained.
You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role.
Experience working with psychiatric and geriatric patient populations
Bilingual (English / Spanish) language proficiency
Careers 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 550,000+ 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)
© 2018 OptumCare. All Rights Reserved.
OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare's support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity / Affirmative Action employers 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
Job Keywords: Case Manager, RN, Registered Nurse, Jacksonville, FL, Florida
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