14 days old

Registered Nurse RN Inpatient Case Manager Healthcare WellMed Texas/Florida

San Antonio, TX 78205
  • Job Code
    888440
  • Jobs Rated
    118th

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 - 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.

 

Primary Responsibilities:

  • In consultation with manager of Care Management collaborates with Interdisciplinary care team (ICT) 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 with guidance from medical directors and Manager of Case Management 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
  • 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 in consultation 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 with supervision in an efficient and effective manner utilizing time management skills
  • Demonstrates knowledge of utilization management and care coordination processes as a foundation for transition planning activities
  • 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 90% or better on a monthly basis
  • Adheres to organizational and departmental policies and procedures
  • Takes on-call assignment as directed with supervision
  • 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
  • Saturday and Sunday Shifts required


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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Jobs Rated Reports for Registered Nurse

Posted: 2020-09-08 Expires: 2020-10-08

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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Registered Nurse RN Inpatient Case Manager Healthcare WellMed Texas/Florida

UnitedHealth Group
San Antonio, TX 78205

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Registered Nurse
118th2018 - Registered Nurse
Overall Rating: 118/220
Median Salary: $70,000

Work Environment
Poor
166/220
Stress
High
173/220
Growth
Good
53/220
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