Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together. The Sr. Case Manager III - 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 Sr. Case Manager is responsible for coordinating the care from admission through discharge. The Sr. Case Manager participates in Patient Care Conferences to review clinical status, update/finalize transition discharge needs, and identify members at risk for readmission. Lastly, the incumbent will serve as a subject matter expert to members of the Case Management Team and will be expected to answer questions or advise other Case Managers when situations arise with which the Sr. Case Manager has had previous experience.This is a 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)Primary Responsibilities:
Serves as key resource/SME to ensure effective collaboration effectively with
Interdisciplinary care team (IDT) to establish an individualized transition plan for members
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
Serves as key resource/SME for performing expedited, standard, concurrent, and retrospective onsite or telephonic clinical reviews at in-network and/or out-of-network facilities. The Sr. Case Manager documents medical necessity and appropriate level of care utilizing national
recognized clinical guidelines
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
Master of knowledge of utilization management and care coordination processes as a foundation for transition planning activities
Serves as key resource/SME 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 90% 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
Functions as a subject matter expert and mentors other case managers to assist in their role and personal/professional development
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.Required Qualifications:
Bachelor’s degree in Nursing and/or Associate’s degree in Nursing combined with 4+ years of experience than the required years of experience
RN license specific to the state of employment
Case Management Certification (CCM) or ability to obtain CCM within 12 months after the first year of employment
7+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
5+ years of managed care and/ or case management experience
Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel
Access to reliable transportation and Case Manager is responsible for maintaining an active driver’s license
Proven ability to utilize critical thinking skills, nursing judgement, and decision making skills
Preferred Qualifications:
Experience working with psychiatric and geriatric patient populations
Bilingual (English/Spanish) language proficiency
Physical & Mental Requirements:
Ability to properly drive and operate a company vehicle
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.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.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.