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.
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
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.
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
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
- UnitedHealth Group Jobs