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Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)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.This position will allow you to telecommute / work from home. It also may include onsite representation to acute and/or post-acute facilities, must live within commuting distance of the office located at 4700 W SAM HOUSTON PARKWAY N HOUSTON TX 77041.There is a $3,000 Sign-On Bonus for qualified external candidatesIf you are located in Houston, TX, you will have the flexibility to telecommute as you take on some tough challenges.Primary Responsibilities:Collaborate 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
Serve as the clinical liaison with hospital, clinical and administrative staff as well as provide expertise for clinical authorizations for inpatient care based on utilized evidenced-based criteria
Perform concurrent and retrospective onsite or telephonic clinical reviews at the designated network or out of network facilities
Document medical necessity and appropriate level of care utilizing national recognized clinical guidelines
Interact 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
Stratify and / or validate 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
Manage assigned case load in an efficient and effective manner utilizing time management skills to facilitate the total work process directly monitoring assigned members
Provide constructive information to minimize problems and increase customer satisfaction
Seek ways to improve job efficiency and make appropriate suggestions following the appropriate chain of command
Demonstrate knowledge of utilization management and care coordination processes and current standards of care as a foundation for transition planning activities
Confer with physician advisors on a regular basis regarding inpatient cases and participate in department case rounds
Plan member transitions, with providers, patient and family
Enter 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
Adhere to organizational and departmental policies and procedures and credentialed compliance
Take on-call assignment as directed
Attend and participates in integrated care team meetings as directed
Solve problems by gathering and /or reviewing facts and selecting the best solution from identified alternatives
Make decisions based on prior practice or policy, with some interpretation
Apply individual reasoning to the solution of problems, devising or modifying processes and writing procedures as necessary
Maintain 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
Refer cases to Medical Director as appropriate for review or requests not meeting criteria or for complex case situations
Participate 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
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, or associate 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 required, 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
Maintain a valid and current driver’s license
Ability to read, analyze and interpret information in medical records, health plan documents and financial reports
Proficient with Microsoft Office applications including Word, Excel, and Power Point
Preferred Qualifications:Experience working with psychiatric and geriatric patient populations
Bilingual (English / Spanish) language proficiency
Case Management Certification (CCM)
Independent problem identification / resolution and decision-making skills
Ability to prioritize, plan, and handle multiple tasks / demands simultaneously
Ability to solve practical problems and deal with a variety of variables
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
Physical & Mental Responsibilities:Ability to lift up to 50 pounds
Ability to push or pull heavy objects using up to 25 pounds of force
Ability to sit for extended periods of time
Ability to stand for extended periods of time
Ability to use fine motor skills to operate office equipment and/or machinery
Ability to properly drive and operate a company vehicle
Ability to receive and comprehend instructions verbally and/or in writing
Ability to use logical reasoning for simple and complex problem solving
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)WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.PLEASE NOTE The Sign On Bonus is only available to external candidates. Candidates who are currently working for a UnitedHealth Group, UnitedHealthcare or a related entity in a full time, part time, or per diem basis (“Internal Candidates”) are not eligible to receive a Sign On Bonus.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: RN Case Manager Inpatient Services WellMed, Case Manager, Medicare, Inpatient, CCM, UM, Utilization Management, Senior, Geriatric, Care Plan, Care Management, Transition Of Care, Houston, TX, Texas
