Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. Bring your skills and talents to a role where you'll have the opportunity to make an impact on a huge scale. This is the place to do your life's best work.(sm) The Telephonic Case Manager is responsible for utilization management and inpatient care management coordination in a telephonic case management position. This position requires heavy telephonic use. The Case Manager will perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Generally work is self-directed and will require solving moderately complex problems and / or moderately complex analyses, including identifying solutions to non-standard requests and problems The Case Manager works under the direct supervision of an RN or MD and will act as a resource for others, coaching, guiding and providing feedback to others as necessary. This function is responsible for medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. The function may also be responsible for providing health education, coaching and treatment decision support for members and will work closely with management teams in the ongoing development and implementation of health services programs. Primary Responsibilities: The Case Manager serves as the telephonic clinical liaison with hospital clinical and administrative staff as well as providing expertise for clinical authorizations for inpatient care Makes outbound calls to assess members' current health status Performs case reviews telephonically for assigned inpatient facilities and skilled nursing facilities; advises supervisor of any potential problems as they become evident Ensures that our members receive the proper levels of care, coordinating their care, and assesses and interprets needs and requirements, in addition to referring patients to disease or case management programs; makes "welcome home" calls to ensure that discharged member receive the necessary services and resources Conduct Utilization Reviews (concurrent and retrospective reviews) using approved health plan guidelines such as Milliman Criteria and / or InterQual Criteria Demonstrate knowledge of utilization management processes and current standards of care as a foundation for utilization review and discharge planning activities Confer with physician advisors on regular basis regarding inpatient cases and participate in utilization departmental rounds. Plans member discharges with providers Track ongoing status of all certification activity and maintain continuing certification (or denial) Make initial assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers Adhere to quality standards and state UR guidelines, as well as confidentiality of all information, policies, and procedures. Adheres to company policies, procedures, and reporting requirements Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research Continuous professional development about issues and trends in utilization review Negotiate price, level of care, intensity, and duration of services as appropriate Performs all other related duties as assigned
**This position is located at WellMed Medical Management Corporate Office** Required Qualifications: Education required: Bachelor's degree in Nursing, or Associate's degree in Nursing combined with 2 or more years of experienceCurrent, unrestricted RN license required, specific to the state of employment Two years of managed care and / or case management experience Three years of clinical experience Knowledge of managed care, medical terminology, referral process, claims and ICD-9 codes Excellent verbal and written skills Skills in planning, organizing, conflict resolution, negotiation and interpersonal skills to work with autonomy in meeting UM goals Knowledge of utilization management and / or insurance review processes as well as current standards of care, a strong knowledge of health care delivery systems and the ability to interact with medical directors, physician advisors, clinicians and support staff The ability to work independently in accomplishing assignments, program goals and objectivesPreferred Qualifications: Case Management certification strongly desired Proficient computer skills in Microsoft applicationsCareers 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 90,000+ 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) 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. Job Keywords: RN, Case Manager, RN Case Manager, Registered Nurse, San Antonio, TX
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need... at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.