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 Case Manager II - Inpatient Services RN 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: 

• Independently collaborates effectively with Interdisciplinary care team (ICT) to establish an individualized transition plan for members
• Independently 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
• 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 for all authorizations
• 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
• Demonstrates exemplary knowledge of utilization management and care coordination processes as a foundation for transition planning activities
  Independently 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
• 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

This is an office/hybrid position near Padre Island Rd

 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
• Current, unrestricted RN license required in the state of TX
• Case Management Certification (CCM) or ability to obtain CCM within 12 months after the first year of employment
• 2+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
• 2+ years of managed care and/or case management experience
• Proven knowledge in Microsoft Office applications including Outlook, Word and Excel
• Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area

Preferred Qualifications: 

• Experience working with psychiatric and geriatric patient populations
• Ability to read, analyze and interpret information in medical records and health plan documents
• Ability to problem solve and identify community resources
• Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
• Ability to prioritize, plan and handle multiple tasks/demands simultaneously
• Utilize critical thinking skills, nursing judgement and decision-making skills

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. 

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