Registered Nurse RN Inpatient Case Manager - Remote from a Compact State

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 RN Case Manager II – Inpatient Services 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. If you are located in a compact state, you will have the flexibility to work remotely* as you take on some tough challenges.

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 Performs all other related duties as assigned