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UnitedHealth Group RN Case Manager Phoenix, AZ in Phoenix, Arizona

The Complex Care Management (CCM) RN Case manager supports Community, Long Term, Assist Living and the Transitions to Skilled programs to ensure care are delivered appropriately and efficiently to eligible members. This position reports to the Quality Manager.

Primary Responsibilities:

  • Receive referrals from the central team or EMR and assigning to the correct APC to notify a new member has been received

  • Assist the management team in the balancing of caseloads and prioritization of critical information pertinent to the member

  • Assist in the collection of demographic and Health Plan information from sources that contain this information

  • Ability to evaluate medical records for skilled needs and interpret the needs to verify benefit eligibility for TTS program

  • Collaborates with the facility staff in assessing the skilled needs of the member to verify eligibility for skilled benefit (external payers only)

  • Notification to external payers of admission and discharge status daily

  • Assists in clerical data entry to facilitate complete information in the EMR

  • Managing incoming calls from providers or SNF’s

  • Managing requests for documentation as needed from external payers and SNF’s or providers

  • Documents all telephonic communication in the EMR regarding status of admission and discharge

  • Performs Concurrent Review functions for Risk Members to determine medical necessity of continued stay according to review standards

  • Reviews and analyzes medical information to determine skilled need/criteria

  • Performs electronic/telephonic review of concurrent patient services and retrospective quality care issues, access and outcomes

  • Maintain ongoing databases/documentation for clinical reports and for utilization reporting

  • Identifies care/quality concerns and escalates reports on the quality of care issues

  • Submits reports and communicates in a timely and effective manner to the Clinical Quality RN Manager

  • Follow relevant regulatory guidelines, policies and procedures in reviewing clinical documentation (e.g. HEDIS, Clinical Practice Guidelines)

  • Manipulate and leverage multiple databases/Electronic Medical Record applications to sort, search, and enter information

Care Coordination:

  • Understand the Payer/Plan benefits, Complex Care Management (CCM) associate policies, procedures and Transitional model of care

  • Coordinate care as members transition through different levels of care and care settings as needed to assist the field staff

  • Facilitate Internal Care Team (ICT) meetings per health plan protocol

  • Facilitation of Transfer Alternative Program (TAP) meetings

  • Establish positive customer relationships with member/Skilled Nurse Facilities and health plans

  • Serves as a liaison between Optum and health plans and facilities

Program Enhancement Expected Behaviors:

  • Regular and effective communication with internal and external parties including physicians, members, key decision-makers, nursing facilities, Complex Care Management (CCM) staff and other provider groups.

  • Exhibits original thinking and creativity in the development of new and improved methods and approaches to concerns/issues.

  • Function independently and responsibly with minimal need for supervision.

  • Demonstrate initiative in achieving individual, team and organizational goals and objectives.

  • Participate in Complex Care Management (CCM) quality initiatives.  

Required Qualifications:

  • Active unencumbered Arizona RN License

  • 2 + years of prior experience in case management and/or utilization management

  • Experience with Electronic Medical Records

  • Excellent communication and customer service skills

  • Ability to navigate a Windows environment, utilize Outlook, and the ability to create, edit, save and send documents utilizing Microsoft Word

  • Must be proficient in the use of MS Excel

Preferred Qualifications:

  • 3 + years of prior experience in case management , prior authorization, utilization Management

  • 1 + year of hands on experience with Quality improvement utilizing HEDIS and STARS measures

OptumCare is committed to creating an environment where physicians focus on what they do best: care for their patients. To do so, OptumCare provides administrative and business support services to both owned and affiliated medical practices which are part of OptumCare. Each medical practice part and their physician employees have complete authority with regards to all medical decision-making and patient care. OptumCare’s support services do not interfere with or control the practice of medicine by the medical practices or any of their physicians.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.

Job Keywords: RN Case Manager, Phoenix, AZ, Arizona