RN Case Manager, Inpatient Services - Remote from a Compact State
Posted 2025-04-06WellMed, part of the Optum family of businesses, is seeking a RN Case Manager to join our team in 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, youÂll be an integral part of our vision to make healthcare better for everyone.
At Optum, youÂll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, youÂll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while 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 Texas, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:  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 memberÂs level of risk by utilizing the Population Stratification tools and communicates during transition process the memberÂs 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
In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors offices. At WellMed our focus is simple. WeÂre innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000 primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000 older adults. Together, we're making health care work better for everyone.
YouÂll 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:  BachelorÂs degree in Nursing and/or, AssociateÂs degree in Nursing combined with 4 or more years of experience above the required years of experience  Current, unrestricted RN license required, specific to the state of employment  Case Management Certification (CCM) or ability to obtain CCM within 12 months after the first year of employment  4 years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions  Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel  Proven ability to read, analyze and interpret information in medical records, and health plan documents  Reliable transportation that will enable you to travel to client and/or patient sites within a designated area
Preferred Qualifications:  3 years of managed care and/ or case management experience  Experience working with psychiatric and geriatric patient populations  Knowledge of utilization management, quality improvement, and discharge planning  Bilingual (English/Spanish) language proficiency  Proven ability to problem solve and identify community resources  Proven ability to utilize critical thinking skills, nursing judgement, and decision making skills  Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously  Proven planning, organizing, conflict resolution, negotiating and interpersonal skills
Physical & Mental Requirements:  Ability to lift up to 25 pounds  Ability to push or pull heavy objects using up to 10 pounds of force  Ability to sit for extended periods of time  Ability to stand for extended periods of time  Ability to use fine motor skills to operate office equipment and/or machinery  Ability to receive and comprehend instructions verbally and/or in writing  Ability to use logical reasoning for simple and complex problem solving
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.
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