13 days old

RN Case Manager Inpatient Services WellMed Corpus Christi - 940581

Corpus Christi, TX 78401
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  • Job Code
    940581

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 lifes best work.(sm)

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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

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Primary Responsibilities:

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  • 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
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  • 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
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  • 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
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  • 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
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  • Stratifies and/or validates patient level of risk and communicates during transition process with the Integrated Care Team
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  • Provide assessments of physical, psycho-social and transition needs in settings not limited to the PCP office, hospital, or members home. Develops interventions and processes to assist the member in meeting short and long term plan of care goals
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  • Manages assigned case load in an efficient and effective manner utilizing time management skills to facilitate the total work process directly monitoring assigned members ""
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    • Provides constructive information to minimize problems and increase customer satisfaction
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    • Seeks ways to improve job efficiency and makes appropriate suggestions following the appropriate chain of command
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  • Demonstrates knowledge of utilization management and care coordination processes and current standards of care as a foundation for transition planning activities
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  • 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
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  • 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
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  • Adheres to organizational and departmental policies and procedures and credentialed compliance""
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    • Takes on-call assignment as directed
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    • Attends and Participates in integrated care team meetings as directed
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  • 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""
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    • Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms
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    • With the assistance of the Managed Care/UM teams, guides physicians in their awareness of preferred contracts and providers and facilities
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  • Refers cases to Medical Director as appropriate for review or requests not meeting criteria or for complex case situations
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  • Participates in the development of appropriate QI processes, establishing and monitoring indicators
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  • 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
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  • Performs all other related duties as assigned
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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.

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Required Qualifications:

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  • Current, unrestricted RN license required, specific to the state of employment
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  • 3+ years of experience in a hospital, acute care or direct care setting
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  • Advanced skills with Microsoft Office applications including Word and Excel
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  • Maintain a valid and current drivers license
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Preferred Qualifications:

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  • BSN
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  • Bilingual (English/Spanish) language proficiency
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  • 1+ years of managed care and/ or case management experience
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  • Case Management Certification (CCM)
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  • Knowledge of utilization management, risk management, quality improvement, discharge planning, and cost management
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  • Experience in a telephonic role
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  • Experience in MCG or InterQual
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Physical & Mental Requirements:

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  • Ability to lift up to 50 pounds
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  • Ability to push or pull heavy objects using up to 25 pounds of force
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  • Ability to sit for extended periods of time
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  • Ability to use fine motor skills to operate office equipment and/or machinery
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  • Ability to receive and comprehend instructions verbally and/or in writing
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  • Ability to use logical reasoning for simple and complex problem solving
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Careers at OptumCare. We're on a mission to change the face of health care. As the largest health and wellness business in the US, we help 58 million people navigate the health care system, finance their health care needs and achieve their health and well-being goals. Fortunately, we have a team of the best and brightest minds on the planet to make it happen. Together we're creating the most innovative ideas and comprehensive strategies to help heal the health care system and create a brighter future for us all. Join us and learn why there is no better place to do your life's best work.(sm)

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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.

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UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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Job Keywords:RN Case Manager Inpatient Services, RN, BSN, Case Management, CCM, utilization review, risk management, telephonic, MCG, InterQual, discharge planning, WellMed, Corpus Christi, TX, Texas

Posted: 2021-07-17 Expires: 2021-08-16

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

Sponsored by:
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RN Case Manager Inpatient Services WellMed Corpus Christi - 940581

UnitedHealth Group
Corpus Christi, TX 78401

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