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Optum Inpatient Case Manager in Colorado Springs, Colorado

General Position Summary:

The Inpatient Case Manager will perform concurrent and retrospective reviews from admission to discharge for hospitals, skilled nursing facilities, long term acute and acute rehabilitation admissions. This position will review for appropriate utilization of medical services by applying appropriate medical necessity criteria and guidelines. In addition, the incumbent will facilitate clinically efficient care and effective discharge planning and utilizes managed care principles and sound nursing judgment in the coordination, development, implementation and evaluation of interdisciplinary plans of care. The Inpatient Case Manager works closely with the Hospitalist and SNF team during the review process. This position is responsible for identifying members who are appropriate for care coordination programs and collaborate with the Medical Management team. Concurrent reviews will be performed telephonically, thru electronic health records and with onsite facility visits when appropriate.

Essential Functions/Responsibilities:

Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes. Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria and guidelines. Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria. Documents clinical reviews, care management interventions and discharge plans in care management system. Provides accurate and timely documentation and supporting rationale of decision in care management system. Utilizes care management system and resources to track and analyze utilization, variances and trends, patient outcomes and quality indicators. Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member’s needs along the continuum of care. Utilizes managed care principles and sound nursing judgment in the coordination, development, implementation and evaluation of interdisciplinary plans of care. Coordinates plan of care with the physician, patient and family members to promote, maintain and restore health. Selects interventions and makes decisions based on an understanding of the patient and family needs. Assists the patient and families in identifying and implementing strategies to cope with the events and stresses of illness and hospitalizations to adapt to the situation. Utilizes knowledge of resources available in the health care system to assist the physician and patient effectively. Responsible for facilitating continuity of care, before, during and after facility discharge. Provides for effective and efficient transitions and handoffs during care coordination. Communicates regularly with Physician/Hospital staff regarding the patient’s status, any identified problems related to appropriateness of services, quality of care or issues that may impact a timely discharge. Successfully completes the Interrater Reliability Testing to ensure consistency of review and application of criteria. Meets timeliness standards for reviews and case management activities. Contributes to the professional growth of members of the Medical Management team. Incorporates principles of health maintenance and promotion, disease prevention, symptom management, patient education and counselling in the performance of care coordination Serves as an advocate for providers and their patients. Demonstrates a positive attitude and respect for self and others and responds in a courteous manner to all customers, internal and external. Develops and implements strategies that maximize the role of the Care Manager and have positive effects on the health care system. Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding company business.

Secondary Functions:

Perform other relevant job duties as assigned.

Supervisory Responsibility:

Individual contributor

Knowledge, Skills, Abilities, Education and Experience:

  • Current unrestricted Colorado RN license; BSN preferred;

  • RN with minimum of 3-5 years in acute care setting;

  • Previous utilization/case management/discharge planning experience;

  • Knowledge of Medicare/Medicaid and InterQual guidelines and appropriate community resources;

  • Coordination with hospital staff and physicians for timely and appropriate discharge and discharge planning

  • Ability to provide accurate and timely documentation of clinical review and supporting rational of decision in care management system.

  • Able to take initiative to identify potential or actual obstacles and works with others to develop solutions.

  • Ability to work independently with minimum supervision.

  • Able to perform various computer software applications with an intermediate level of competence.

Job Conditions:

  • Job requires hours that may exceed 8 hours per day and/or 40 hours per week during times of peak activity. Attendance of morning or evening events with prospective patients, employed or affiliate physicians required.

  • Must be willing to travel up and down the Front Range.

  • Moderate to high job pressure exists in the balancing of several projects with conflicting and sometimes changing deadlines. Physical capability to occasionally lift up to 30 pounds.

  • You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role.

  • Employees are required to screen for symptoms using a UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained.

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM)

Diversity creates a healthier atmosphere: Optum and its affiliated medical practices are 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. Optum and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

For Colorado Residents Only: The range for Colorado residents is $65,000 to $80,000. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are based on eligibility). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.