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.
Primary 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. The Case Manager 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
- The 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 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
- Performs all other related duties as assigned
In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors' offices. At WellMed our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- Bachelor's degree in Nursing and/or, Associate's degree in Nursing combined with 4+ years of experience above the required years of experience
- Current, unrestricted RN license 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
- Knowledgeable in Microsoft Office applications including Outlook, Word, and Excel
- Proven ability to read, analyze and interpret information in medical records, and health plan documents
- Proven ability to problem solve and identify community resources
- Proven planning, organizing, conflict resolution, negotiating and interpersonal skills
- Proven ability to utilize critical thinking skills, nursing judgement, and decision making skills
- Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously
- Proven ability to be in a stationary position or move for prolonged periods
- Reliable transportation and Case Manager is responsible for maintaining an active driver's license
Preferred Qualifications:- Experience working with psychiatric and geriatric patient populations
- Bilingual (English/Spanish) language proficiency
Physical & Mental Requirements: - Ability to lift up to 25 pounds
- Ability to push or pull heavy objects using up to 10 pounds of force
- Ability to sit for extended periods of time
- Ability to stand for extended periods of time
- Ability to use fine motor skills to operate office equipment and/or machinery
- Ability to receive and comprehend instructions verbally and/or in writing
- Ability to use logical reasoning for simple and complex problem solving
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.
