12 days old

RN Case Manager Inpatient Services WellMed - Houston, TX - 937255

Houston, TX 77002
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  • Job Code
    937255

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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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.

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If you are located in Houston, Texas, you will have the flexibility to telecommute* as you take on some tough challenges.

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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.

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There is a $3,000 Sign-On Bonus for qualified external candidates

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Primary Responsibilities:

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  • Collaborate effectively with integrated care team (ICT) to establish an individualized plan of care for members
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  • The interdisciplinary care team develops interventions to assist the member in meeting short and long term plan of care goals
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  • 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
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  • Perform concurrent and retrospective onsite or telephonic clinical reviews at the designated network or out of network facilities
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  • Document medical necessity and appropriate level of care utilizing national recognized clinical guidelines
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  • 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
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  • Stratify and / or validate 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
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  • Develops interventions and processes to assist the member in meeting short and long term plan of care goals
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  • Manage 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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  • Provide constructive information to minimize problems and increase customer satisfaction
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  • Seek ways to improve job efficiency and make appropriate suggestions following the appropriate chain of command
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  • Demonstrate knowledge of utilization management and care coordination processes and current standards of care as a foundation for transition planning activities
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  • Confer with physician advisors on a regular basis regarding inpatient cases and participate in department case rounds
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  • Plan member transitions, with providers, patient and family
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  • 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
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  • Adhere to organizational and departmental policies and procedures and credentialed compliance
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  • Take on-call assignment as directed
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  • Attend and participates in integrated care team meetings as directed
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  • Solve problems by gathering and /or reviewing facts and selecting the best solution from identified alternatives
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  • Make decisions based on prior practice or policy, with some interpretation
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  • Apply individual reasoning to the solution of problems, devising or modifying processes and writing procedures as necessary
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  • Maintain 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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  • Refer cases to Medical Director as appropriate for review or requests not meeting criteria or for complex case situations
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  • Participate 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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Youll 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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  • Bachelors degree in Nursing, or associate degree in Nursing and Bachelors degree in related field, or Associates degree in Nursing combined with 4+ years of experience
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  • Current, unrestricted RN license required, specific to the state of employment
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  • 2+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
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  • 1+ years of managed care and/ or case management experience
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  • Knowledge of utilization management, quality improvement, discharge planning, and cost management
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  • Maintain a valid and current drivers license
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  • Ability to read, analyze and interpret information in medical records, health plan documents and financial reports
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  • Ability to solve practical problems and deal with a variety of variables
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  • Proficient with Microsoft Office applications including Word, Excel, and Power Point
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  • 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 doctors diagnosis of disease
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  • If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders
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Preferred Qualifications:

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  • Experience working with psychiatric and geriatric patient populations
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  • Bilingual (English / Spanish) language proficiency
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  • Case Management Certification (CCM)
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  • Independent problem identification / resolution and decision-making skills
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  • Ability to prioritize, plan, and handle multiple tasks / demands simultaneously
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  • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
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Physical & Mental Responsibilities:

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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 stand 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 properly drive and operate a company vehicle
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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 with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors., WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for 550,000+ older adults with over 16,000 doctors offices 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)

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*All Telecommuters will be required to adhere to UnitedHealth Groups Telecommuter Policy

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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: Case Manager, Medicare, Inpatient, CCM, UM, Utilization Management, Senior, Geriatric, care plan, care management, transition of care, Houston, TX, Texas

Posted: 2021-07-12 Expires: 2021-08-11

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.

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RN Case Manager Inpatient Services WellMed - Houston, TX - 937255

UnitedHealth Group
Houston, TX 77002

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