Utilization Manager

WellMed, part of the Optum family of businesses, is seeking a Registered Nurse Case or Utilization Manager to join our team in Texas. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Nurse Case Manager II (NCM) is responsible for patient case management for longitudinal engagement, coordination for discharge planning, transition of care needs and outpatient patient management through the care continuum. Nurse Case Manager will identify, screen, track, monitor and coordinate the care of patients with multiple co-morbidities and/or psychosocial needs and develop a patients’ action plan and/or discharge plan. They will perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. The Nurse Case Manager will 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 Nurse Case Manager will coordinate, or provide appropriate levels of care under the direct supervision of an RN Manager or MD. Function is responsible for clinical operations and 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. Function may also be responsible for providing health education, coaching and treatment decision support for patients.  The Nurse Case Manager will act as an advocate for patients and their families guide them through the health care system for transition planning and longitudinal care. The Nurse Case Manager will work in partnership with an assigned Care Advocate and Social Worker.

If you are located in Texas, you will have the flexibility to work remotely* as you take on some tough challenges. Must have a Compact License.

Primary Responsibilities:

• Engage patient, family, and caregivers telephonically to assure that a well-coordinated action plan is established and continually assess health status 
• Provide member education to assist with self-management goals; disease management or acute condition and provide indicated contingency plan
• Identify patient needs, close health care gaps, develop action plan and prioritize goals
• Utilizing evidenced-based practice, develop interventions while considering member barriers independently
• Provide patients with ‘welcome home‘ calls to ensure that discharged patients’ receive the necessary services and resources according to transition plan
• Conducts a transition discharge assessment onsite and/or telephonically to identify member needs at time of transition to a lower level of care
• 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 for discharge planning and/or next site of care needs
• In partnership with care team triad, make referrals to community sources and programs identified for patients
• Utilize motivational interviewing techniques to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy
• Manages assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers
• Collaborates effectively with Interdisciplinary Care Team (IDCT) to establish an individualized transition plan and/or action plan for patients
• Independently confers with UM Medical Directors and/ or Market Medical Directors on a regular basis regarding inpatient cases and participates in departmental huddles
• Demonstrate knowledge of utilization management processes and current standards of care as a foundation for utilization review and transition planning activities
• Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research
• Manage assigned caseload in an efficient and effective manner utilizing time management skills
• Enters timely and accurate documentation into designated care management applications to comply with documentation requirements and achieve audit scores of 95% or better on a monthly basis
• Maintain current licensure to work in state of employment and maintain hospital credentialing as indicated
• Performs all other related duties as assigned

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we‘re making health care work better for everyone.

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:

• Associate’s degree in Nursing
• Current, unrestricted 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
• 3+ years of diverse clinical experience; preferred in caring for the acutely ill patients with multiple disease conditions
• 3+ years of managed care and/or case management experience
• Proven knowledge of utilization management, quality improvement, and discharge planning
• Availability for weekend shift

Preferred Qualifications:

• Experience working with psychiatric and geriatric patient populations
• Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel
• Proven ability to read, analyze and interpret information in medical records, and health plan documents
• Proven ability to problem solve and identify community resources
• Proven possess in planning, organizing, conflict resolution, negotiating and interpersonal skills
• Proven ability to independently utilizes critical thinking skills, nursing judgement and decision-making skills. Ability to prioritize, plan, and handle multiple tasks/demands simultaneously

Physical & Mental Requirements:

• Ability to lift up to 10 pounds
• Ability to push or pull heavy objects using up to 25 pounds of force
• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 

Diversity creates a healthier atmosphere: OptumCare 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.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment