RN Case Manager, Inpatient Services - Remote from Texas

About the position The RN Case Manager, Inpatient Services at WellMed, part of the Optum family, is responsible for coordinating care for patients in various healthcare settings, including acute hospitals and skilled nursing facilities. This role involves collaborating with an integrated care team to develop and implement individualized care plans, ensuring continuity of care from admission through discharge. The position emphasizes the importance of effective communication, clinical review, and adherence to established guidelines to improve patient outcomes and reduce readmissions.

Responsibilities

• Collaborates effectively with integrated care team (ICT) to establish an individualized plan of care for members.
• Serves as the clinical liaison with hospital, clinical and administrative staff, providing expertise for clinical authorizations for inpatient care.
• Performs concurrent and retrospective onsite or telephonic clinical reviews at designated facilities.
• Documents medical necessity and appropriate level of care utilizing nationally recognized clinical guidelines.
• Interacts and effectively communicates with facility staff, members, and their families to assess discharge needs and formulate discharge plans.
• Stratifies and validates patient level of risk and communicates during the transition process with the Integrated Care Team.
• Provides assessments of physical, psycho-social, and transition needs in various settings.
• Develops interventions and processes to assist members in meeting care goals.
• Manages assigned case load efficiently, utilizing time management skills.
• Provides constructive feedback to minimize problems and increase customer satisfaction.
• Seeks ways to improve job efficiency and makes appropriate suggestions.
• Demonstrates knowledge of utilization management and care coordination processes.
• Confers with physician advisors regarding inpatient cases and participates in department case rounds.
• Plans member transitions with providers, patients, and families.
• Enters timely and accurate data into care management applications.
• Adheres to organizational and departmental policies and procedures.
• Takes on-call assignments as directed.
• Attends and participates in integrated care team meetings.
• Problem solves by gathering and reviewing facts to select the best solution.
• Maintains current knowledge of health plan benefits and provider network.
• Guides physicians in awareness of preferred contracts and providers.
• Refers cases to Medical Director as appropriate.
• Participates in the development of quality improvement processes.
• Performs comprehensive assessments and documents findings in compliance with regulations.

Requirements

• Bachelor's degree in Nursing, or Associate's degree in Nursing and Bachelor's degree in related field, or Associate's degree in Nursing combined with 4+ years of experience.
• Current, unrestricted RN license specific to the state of employment.
• 2+ years of diverse clinical experience in caring for acutely ill patients with multiple disease conditions.
• 1+ years of managed care and/or case management experience.
• Knowledge of utilization management, quality improvement, discharge planning, and cost management.
• Proficient with Microsoft Office applications including Word, Excel, and PowerPoint.
• Proven ability to read, analyze, and interpret information in medical records and health plan documents.
• Proven ability to solve practical problems and deal with a variety of variables.
• Proven planning, organizing, conflict resolution, negotiating, and interpersonal skills.
• Proven independent problem identification/resolution and decision-making skills.
• Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously.
• Ability to maintain a valid and current driver's license.
• Ability to frequently move or be in a stationary position for prolonged periods.

Nice-to-haves

• Case Management Certification (CCM).
• Experience working with psychiatric and geriatric patient populations.
• Bilingual (English/Spanish) language proficiency.

Benefits

• Flexible work options including remote work for Texas residents.
• Opportunities for professional development and career advancement.
• Supportive work environment focused on diversity and inclusion.

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