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Gonzales, United States UnitedHealth Group Full time**WellMed, part of the Optum family of businesses, is seeking a Registered Nurse RN Quality Auditor WellMed Healthcare to join our team in San Antonio, 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 Case Manager
2 months ago
Join the WellMed Team, a vital part of the Optum family, dedicated to providing exceptional healthcare services. Our mission is to ensure that every patient receives the highest standard of medical attention. Here, you will collaborate with a team that shares your commitment to enhancing patient health outcomes. With a variety of roles available for healthcare professionals, you can make a significant impact as you embrace the essence of
Caring. Connecting. Growing together.
The primary role of the Case Manager involves identifying, screening, tracking, monitoring, and coordinating care for members with complex health conditions and psychosocial needs, while developing comprehensive case management plans.
Collaboration with an interdisciplinary care team (IDT) is essential, including physicians, inpatient case managers, care team associates, pharmacists, social workers, educators, and healthcare coordinators/managers.
As an advocate for members and their families, the Case Manager connects them with IDT members to enhance their understanding of their health conditions and to identify community resources that promote independence.
Participation in IDT conferences is crucial for reviewing care plans and tracking member progress towards established goals and interventions. The Case Manager may conduct assessments via phone or in-person.
Key Responsibilities:
In collaboration with the Care Management manager, conduct initial assessments for members with complex needs within specified time frames (assessing clinical, behavioral, social, environmental, and financial factors).
Work with the IDT to create personalized care plans that include interventions aimed at helping members achieve both short-term and long-term goals.
Engage with patients, families, and caregivers to ensure a well-coordinated care plan is in place.
Identify member needs, develop care plans, and prioritize goals; utilizing evidence-based practices, the Case Manager will formulate interventions while considering barriers, with guidance from medical directors and the Care Management manager.
Make outbound calls to evaluate member health status and identify any gaps or obstacles in the care plan.
Provide education to members to support self-management goals.
Refer members to external resources as needed.
Educate members about their health conditions and provide contingency plans with input from medical directors and the Care Management manager.
Coordinate visits with primary care providers and specialists on a limited basis, perform visual assessments for skin checks, and conduct home safety evaluations.
Enter accurate and timely data into designated care management systems while maintaining audit scores of 90% or higher monthly.
Adhere to all organizational and departmental policies and procedures.
Accept on-call assignments as directed.
Maintain current licensure to practice in the state of employment, making decisions based on regulatory requirements, policies, and clinical guidelines.
Stay informed about health plan benefits and provider networks, including contract inclusions and exclusions.
Monitor quality concerns regarding member care and report as required.
Perform other related duties as assigned.
This is a full-time field-based position requiring travel to support WellMed patients. Candidates must have reliable transportation and be available for flexible shifts, including rotating on-call duties.
At WellMed, you will be recognized for your contributions in an environment that challenges you and provides clear direction for success in your role, as well as opportunities for development in other areas of interest.
Required Qualifications:
Bachelor's degree in Nursing or an Associate's degree in Nursing with 2+ years of experience, or a Nursing Diploma.
Current unrestricted Registered Nurse license for the state of employment.
Case Management certification (CCM) or the ability to obtain CCM within 12 months of employment.
3+ years of diverse clinical experience caring for acutely ill patients with multiple health conditions.
2+ years of experience in managed care and/or case management.
Strong knowledge of utilization management, quality improvement, and discharge planning.
Proficient in Microsoft Office applications, including Outlook, Word, and Excel.
Demonstrated ability to apply critical thinking, nursing judgment, and decision-making skills. Must be capable of prioritizing, planning, and managing multiple tasks simultaneously.
Proven ability to read, analyze, and interpret medical records and health plan documents.
Strong problem-solving skills and the ability to identify community resources.
Excellent planning, organizing, conflict resolution, negotiation, and interpersonal skills.
Access to reliable transportation for travel to client and/or patient sites within a designated area.
This position requires Tuberculosis screening and proof of immunity to certain diseases through lab confirmation, vaccination documentation, or a doctor's diagnosis.
Preferred Qualifications:
Experience with psychiatric and geriatric patient populations.
Physical Qualifications:
Ability to frequently stand, walk, or sit for extended periods.
- At UnitedHealth Group, our mission is to support healthier lives and improve the health system for everyone.
