Registered Nurse Rn Inpatient Case Manager Mcallen Texas

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 Inpatient RN Case Manager 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. Participates in integrated care team conferences to review clinical assessments, update care plans, identify members at risk for readmission and to finalize discharge plans.

Primary Responsibilities:

• Collaborates effectively with integrated care team (ICT) to establish an individualized plan of care for members; the interdisciplinary care team develops interventions to assist the member in meeting short and long term plan of care goals
• Serves as the clinical liaison with hospital, clinical and administrative staff as well as provides expertise for clinical authorizations for inpatient care. based on utilized evidenced-based criteria
• Performs concurrent and retrospective onsite or telephonic clinical reviews at the designated network or out of network facilities; documents medical necessity and appropriate level of care utilizing national recognized clinical guidelines
• Interacts and effectively communicates with facility staff, members and their families and/or designated representative to assess discharge needs and formulate discharge plan and provide health plan benefit information
• Stratifies and/or validates patient level of risk and communicates during transition process with the Integrated Care Team
• Provide assessments of physical, psycho-social and transition needs in settings not limited to the PCP office, hospital, or member’s home; develops interventions and processes to assist the member in meeting short and long term plan of care goals
• Manages assigned case load in an efficient and effective manner utilizing time management skills to facilitate the total work process directly monitoring assigned members
• Demonstrates knowledge of utilization management and care coordination processes and current standards of care as a foundation for transition planning activities
• Confers with physician advisors on a regular basis regarding Inpatient Cases and participates in department case rounds. Plans member transitions, with providers, patient and family
• Problem solving by gathering and /or reviewing facts and selecting the best solution from identified alternatives; decision-making is usually based on prior practice or policy, with some interpretation; must apply individual reasoning to the solution of problems, devising or modifying processes and writing procedures as necessary
• Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms
• Refers cases to Medical Director as appropriate for review or requests not meeting criteria or for complex case situations
• Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations

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:

• Education:
  • 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 Texas RN license or compact state RN license
• Case Management Certification (CCM) or ability to obtain CCM within one year of employment
• 5+ years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions
• 2+ 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 Power Point
• Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area
• This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor’s diagnosis of disease

Preferred Qualifications:

• Experience working with psychiatric and geriatric patient populations
• Proven ability to read, analyze and interpret information in medical records, health plan documents and financial reports

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group 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.

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