Rn High Risk Case Manager
1 month ago
At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start **Caring. Connecting. Growing together.**
Positions in this function require various nurse licensure and certification based on role and grade level. 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, duties may include disease management activities and assist to impact, NCQA and/or HEIDIS results. The High-Risk Nurse Case Manager would be responsible for managing competing priorities which could range from securing, coordinating and authorizing skilled nursing services timely, review hospice or nursing progress notes routinely and provide direction as to ongoing need for continued services, completing initial assessment for newly enrolled hospitalized members, conducting home visits to evaluate for post hospitalization needs. These visits may be completed independently or jointly with the assigned case manager.
If you are located in Phoenix, AZ - Maricopa/Pinal Counties, you’ll enjoy the flexibility to work remotely
- as you take on some tough challenges.
**Primary Responsibilities**:
- Make outbound calls, receive inbound calls, coordinate initial orders for home health nursing, enter authorizations, seek/review clinical records every 60 days and documentation
- The High-Risk Nurse would interact with prescribers to offer recommendations to treatment plans, including cost effective alternatives, such as outpatient clinical supports, pharmacy supports or referrals to alternative care management programs
- The High-Risk Case Manager will assist the assigned LTSS Case Manager with clinically challenging or complex membership which may include completion of field visits and/or telephonic interventions with the member to offer education to assist with self-management
- The High-Risk Nurse works closely with its home bound network of providers (labs, eye professionals, nurses and imaging centers) to ensure quality delivery of services
- Provide additional coverage and support to High-Risk Nurse Case Management Team which could include the completion of initial assessments for newly enrolled members eligible during a hospitalization and actively participate in the discharge process, coordinate or authorize services, supplies or initial placement as applicable
- The position focuses on improving care coordination between the member, their physicians, and caregivers. The purpose of this special approach to case management is to help reduce health care costs by coordinating, authorizing, and monitoring skilled nursing services
- The High-Risk Nurse Case Manager shall have a reliable vehicle, expect to spend up to 50% of their time in the field assessing members in their homes or hospitals
- The High-Risk Nurse Case Manager need to be flexible, adaptable, organized, demonstrate problem-solving skills to assess for alternatives
- Possess knowledge of ALTCS, NCQA and may be engaged in audit activities to further support LTC adherence activities
- Other duties as specified
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**:
- Current, unrestricted Arizona RN license
- A background in managed care
- Able to type and ability to navigate a Windows based environment
- Have a reliable vehicle, ability to travel up to 50% of the time in the field assessing members in their homes or hospitals throughout the Maricopa/ Pinal Counties
- Live in Arizona
**Preferred Qualifications**:
- BSN
- 3+ years of experience in a hospital, acute care, or direct care setting
- Case management experience
- Experience or exposure to discharge planning
- Experience in utilization review, concurrent review or risk management
- Knowledge and experience with Medicare/Medicaid programs
**Competencies**:
- Function independently and responsibly with mínimal need for supervision
- Maintain direct and open communication with all levels of the organization
- Demonstrate initiative in achieving individual, team, and organizational goals and objectives
- Organize work and develop strategies for adapting to a constantly changing workload or when confronted with unforeseen situations
- All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommut
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