RN Case Manager - Hospital Utilization and Transitions of Care

Daily Operational Responsibilities

Daily operational responsibilities include utilization management, discharge planning, referral facilitation and/or collaboration with hospital-based case managers/physicians to move patients to appropriate level of care. Provide interdisciplinary team communication about the hospital stays.

Primary Responsibilities

• Assess, plan and implement care strategies that are individualized by patients and directed toward the most appropriate, least restrictive level of care
• Utilize both company and community-based resources to establish a safe and effective case management plan for hospitalized members
• Collaborate with patient, family and health care providers to develop an individualized plan of care that encompasses both acute care episode and post-hospital discharge plan
• Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all hospitalized members
• Advocate for patients and families as needed to ensure the patient's needs and choices are fully represented and supported by the healthcare team
• Utilize approved clinical criteria to assess and determine appropriate level of care for hospitalized members
• Understand insurance products, benefits, coverage limitations, insurance and governmental regulations as it applies to the health plan
• Coordinate hand-off of care to primary care provider

Required Qualifications

• High School diploma and/or equivalent
• Active unrestricted Nevada RN license
• Ability to obtain CCM certification within two years of employment
• 2+ years of varied clinical experience in a hospital or clinical setting with an emphasis on case management
• Experience in a managed care organization
• Knowledge of utilization management in a managed care environment
• Independent case management knowledge and skills to formulate plans of care without direct supervision
• Understanding of spectrum of alternative delivery systems
• Ability to use computer-based programs and applications
• Demonstrated initiative toward problem solving without direct supervision
• Proven solid organizational, written, oral computer skills
• Proven excellent problem-solving skills
• Proven ability to negotiate with professionals, patients, and caregivers
• Critical Thinking: Proven ability to integrate guidelines/tools to negotiate most effective plan of care. Formulate plans that incorporate the health plan benefits, community services and patient self-direction
• Valid Nevada driver's license and maintain personal auto insurance coverage

Preferred Qualifications

• Bachelor's degree
• Knowledge of Interqual or Milliman guidelines
• Recent Emergency Room hospital care or hospital discharge planning

Pay and Benefits

The hourly pay for this role will range from $35 to $63 per hour based on full-time employment. We comply with all minimum wage laws as applicable. OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.