RN Inpatient Case Manager - Hybrid

Full-time - Mid Level

Remote - Houston, TX

Insurance Carriers and Related Activities

About the position

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. This is a full-time field-based position which requires 25% to 50% traveling around the Houston, TX and counties areas supporting WellMed Patients. The 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 reside in Houston, Texas, you'll enjoy the flexibility to work from home and the office in this hybrid role as you take on some tough challenges.

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.
• 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 member's level of risk by utilizing the Population Stratification tools and communicates during transition process the member's 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.
• Maintains 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.

Requirements

• Bachelor's degree in Nursing and/or, Associate's 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.
• 3+ years of managed care and/or case management experience.
• Knowledge of utilization management, quality improvement, and discharge planning.
• Ability to read, analyze and interpret information in medical records, and health plan documents.
• Ability to problem solve and identify community resources.
• Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
• Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel.
• Utilize critical thinking skills, nursing judgement, and decision-making skills.
• Ability to prioritize, plan, and handle multiple tasks/demands simultaneously.

Nice-to-haves

• Experience working with psychiatric and geriatric patient populations.
• Bilingual (English/Spanish) language proficiency.

Benefits

• Work from home
• Flexible work environment
• Health insurance
• Paid time off
• Retirement savings plan
• Professional development opportunities