The RN Case Manager monitors real-time 'Admit, Discharge, Transfer' (ADT) notifications to provide proactive patient and provider outreach and discharge coordination to support optimal transitions of care. Actively supports ED discharge follow-up care utilizing approved clinical guidelines to transition and provide continuity of care for members to an appropriate next site of care in collaboration with the hospitals/physician team and available outpatient ecosystem resources (PCP, specialist, in-home care, etc.). This position requires a candidate that can be flexible, adapting as the program grows to meet the needs of the populations and markets.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. Must have compact licenses and the ability to obtain other RN non-compact License.
Primary Responsibilities
- Independently collaborates effectively with ED and outpatient care teams to establish an individualized transition plan for members
- Independently serves as the clinical liaison with hospital, clinical and administrative staff and performs transition of care/care coordination for ED discharges using evidenced- based criteria within the documentation system
- Performs expedited, standard, concurrent, and retrospective clinical reviews at in network and/or out of network facilities
- Interacts and effectively communicates with ED 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 ED discharge support opportunities level of risk by monitoring real- time ADT feeds and communicates with patient, ED, and outpatient teams for discharge coordination
- Conducts transition of care outreach following ED discharge to confirm access and completion of discharge plan
- 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
- Enters timely and accurate documentation into designated applications to comply with documentation requirements and achieve audit scores of 90% or better monthly
- Records required information into designated program tracker accurately and timely, ensuring proper KPI measurements, achieving audit scores of 90% or better monthly
- Adheres to organizational and departmental policies and procedures
- Takes on-call assignment as directed
- The ED Case Manager will also 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 for additional support/management as deemed appropriate, following all mandated reporting laws and ethical bounds
- Monitors for any quality concerns regarding member care and reports as per policy and procedure
- Uses, protects, and discloses Optum patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
- Performs all other related duties as assigned
Required Qualifications
- Current, unrestricted Multistate RN license
- 4+ years of diverse clinical experience in caring for acutely ill patients with multiple disease conditions
- 1+ years experience working in the Emergency Department
- Knowledge of utilization management, quality improvement, and discharge planning
- Rapid acuity-based clinical prioritization
- Recognizing early signs of clinical deterioration
- Identifying patients at risk for ED return visits or avoidable bounce-backs
- Credibility with ED physicians and staff*
- Understanding ED workflow, throughput, and provider decision-making*
Preferred Qualifications
- Experience with managed care and/or case management experience
- Understanding ED workflow, throughput, and provider decision-making
*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
The hourly pay for this role will range from $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable.