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 Nurse Case Manager II (NCM) is responsible for patient case management for longitudinal engagement, coordination for discharge planning, transition of care needs and outpatient patient management through the care continuum. Nurse Case Manager will identify, screen, track, monitor and coordinate the care of patients with multiple co-morbidities and/or psychosocial needs and develop a patients’ action plan and/or discharge plan. They will perform reviews of current inpatient services and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. The Nurse Case Manager will 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 Nurse Case Manager will coordinate, or provide appropriate levels of care under the direct supervision of an RN Manager or MD. Function is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. Function may also be responsible for providing health education, coaching and treatment decision support for patients. The Nurse Case Manager will act as an advocate for patients and their families guide them through the health care system for transition planning and longitudinal care. The Nurse Case Manager will work in partnership with an assigned Care Advocate and Social Worker.
If you are located in Within the West TX area, you will have the flexibility to telecommute* as you take on some tough challenges.
Engage patient, family, and caregivers telephonically to assure that a well-coordinated action plan is established and continually assess health status
Provide member education to assist with self-management goals; disease management or acute condition and provide indicated contingency plan
Identify patient needs, close health care gaps, develop action plan and prioritize goals
Utilizing evidenced-based practice, develop interventions while considering member barriers independently
Provide patients with "welcome home" calls to ensure that discharged patients’ receive the necessary services and resources according to transition plan
Conducts a transition discharge assessment onsite and/or telephonically to identify member needs at time of transition to a lower level of care
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 for discharge planning and/or next site of care needs
In partnership with care team triad, make referrals to community sources and programs identified for patients
Utilize motivational interviewing techniques to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy
Manages assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers
Collaborates effectively with Interdisciplinary Care Team (IDCT) to establish an individualized transition plan and/or action plan for patients
Independently confers with UM Medical Directors and/ or Market Medical Directors on a regular basis regarding inpatient cases and participates in departmental huddles
Demonstrate knowledge of utilization management processes and current standards of care as a foundation for utilization review and transition planning activities
Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research
Manage assigned caseload in an efficient and effective manner utilizing time management skills
Enters timely and accurate documentation into designated care management applications to comply with documentation requirements and achieve audit scores of 95% or better on a monthly basis
Maintain current licensure to work in state of employment and maintain hospital credentialing as indicated
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.
Associate’s degree in Nursing
Current, unrestricted RN license, specific to the state of employment or a compact nursing license
Case Management Certification (CCM) or ability to obtain CCM within 12 months after the first year of employment
3+ years of diverse clinical experience; preferred 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
Experience working with psychiatric and geriatric patient populations
Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel Ability to read, analyze and interpret information in medical records, and health plan documents
Bilingual (English/Spanish) OR (English/Vietnamese) language proficiency
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
Independently utilizes critical thinking skills, nursing judgement and decision-making skills
Ability to problem solve and identify community resources
Ability to prioritize, plan, and handle multiple tasks/demands simultaneously
Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
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.
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.