UnitedHealth Group - Cameron, TX

posted 26 days ago

Full-time - Manager
Cameron, TX
10,001+ employees
Insurance Carriers and Related Activities

About the position

The Manager RN Case Management position at WellMed, part of the Optum family, involves overseeing the operations of all Case Management programs in McAllen, Texas. The role focuses on facilitating communication, ensuring compliance with regulations, and leading a team in medical management initiatives. The manager will collaborate with various healthcare professionals to enhance care coordination and improve patient outcomes.

Responsibilities

  • Supports case management operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring, and evaluating)
  • Oversees care management functions and ensures compliance with application of criteria from approved standardized guidelines, government mandated regulations and contractual agreements, including NCQA, URAC, and CMS
  • Engages in Care Team forums/meetings to support care coordination activities between the market providers and the case management team
  • Plans, organizes and oversees staff to ensure timely completion of UM determinations, discharge planning and case management assessments
  • Ensures team meets established performance metrics and medical cost reduction goals, including timely reporting of monthly KPIs
  • Adapts departmental plans and priorities to address business and operational challenges
  • Oversees the team's daily staffing requirements to meet program standards
  • Implements and interprets organizational policies and procedures, reviews work of staff to ensure that policies and guidelines are appropriately applied
  • Tracks and trends outcomes for potential improvements in the care management process, creating and disseminating program and productivity reports weekly, monthly, and as needed
  • Interviews, hires, and retains staff to meet the needs of the department
  • Evaluates staff performance and recommends merit increases, promotions, and disciplinary actions
  • Attends and assists with the facilitation of local market intra-disciplinary care team meetings
  • Monitors and oversees the reporting of all quality issues to medical management leadership for referral and reporting to health plans as appropriate
  • Monitors appropriate utilization of resources, overtime, supplies and mileage
  • Performs comprehensive assessments and documents findings in a concise/comprehensive manner that is compliant with documentation requirements and CMS regulations
  • Performs all other related duties as assigned

Requirements

  • Bachelor of Science in Nursing (BSN) or equivalent experience
  • Current unrestricted RN license in the applicable state or active NP license
  • CCM certification or proof that certification has been obtained within one year of hire date
  • 5+ years of healthcare experience including managed care, hospital, or physician practice settings
  • 3+ years of demonstrated supervisory or management experience
  • Solid experience with MS Office including Word, Excel, and Outlook
  • Ability to establish and maintain effective working relationships with various stakeholders
  • Data mining, analytical and reporting skills
  • Solid organizational skills and multitasking abilities
  • Ability to travel as necessary

Nice-to-haves

  • Master's Science in Nursing
  • Prior multi-site regional operations management responsibility

Benefits

  • Competitive salary
  • Comprehensive health insurance
  • 401k retirement plan
  • Paid time off
  • Professional development opportunities
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