Registered Nurse Inpatient Case Manager Healthcare WellMed San Antonio, TX
Location: San Antonio, Texas
Internal Number: 117517720
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 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.
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 95% 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
Full-Time Office-IH10W/Field Base/Hybrid Position: This position requires 25% - 50% traveling around the San Antonio, TX, and counties areas: Performing onsite review/telephonic clinical reviews of inpatient admissions in an acute hospital, rehabilitation facility, LTAC or skilled nursing facility. Required rotating on-calls (2 – 3 weekends per year)
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 and/or, Associate’s degree in Nursing combined with 4+ years of experience above the required years of experience
Current, unrestricted RN license required, specific to the state of employment
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
Ability to read, analyze and interpret information in medical records, and health plan documents
Ability to problem solve and identify community resources
Frequently required to stand, walk or sit for prolonged periods
Access to reliable transportation
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
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
Experience working with psychiatric and geriatric patient populations
Bilingual (English/Spanish) language proficiency
Utilize critical thinking skills, nursing judgement, and decision making skills
Able to prioritize, plan, and handle multiple tasks/demands simultaneously
Planning, organizing, conflict resolution, negotiating and interpersonal skills
Physical & Mental Requirements:
Ability to lift up to 25 pounds
Ability to push or pull heavy objects using up to 10 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 receive and comprehend instructions verbally and/or in writing
Ability to use logical reasoning for simple and complex problem solving
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment
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: 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
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