The Dual Special Needs Plan (DSNP) Optum at Home program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of members in their place of residence. The DSNP program combines Optum trained clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, which includes the Optum clinician, the member's Primary Care Provider and other providers, and other professionals. Optum providers serve people in their own homes through annual evaluations, ongoing visits for higher risk members, care coordination during transitions from the hospital or nursing home and ongoing care management.
The RN Utilization Manager is accountable for HCBS Review Case Managers who perform evaluation of Home and Community Based Services (HCBS) of members in the Optum at Home Long Term Services and Support program. In collaboration with Optum Medical Director, this position is responsible for HCBS Review outcomes, business operation targets and overseeing the work activities of HCBS Review team.
Primary Responsibilities:- Set team direction, resolve problems, and provide guidance to members of own team
- Lead, supervise, and develop members of the DSNP clinical team utilizing the weekly Grand Rounds for teaching and training activities related to HCBS review and care planning for members
- Oversee work activities of other supervisors and staff with formal monthly HCBS Review manager meetings and participation in All Staff Training Sessions regarding HCBS review topics
- Adapt departmental plans and priorities to address business and operational challenges
- Responsible for policies and procedures for the authorization, oversight and monitoring of member's long-term services and support
- Influence and/or provide input to forecasting and planning activities
- Ensures the team meets established performance metrics and performance guarantees through Clinical Utilization Excellence rounds with case presentation to identify services and resources that align with members' care needs and development of care plan and assist with Transition of Care discussions
- Ensure effective orientation and development for Clinical Staff in collaboration with New Hire Orientation Training team covering HCBS review work
- Utilize Complex Population Management performance tools that hold the clinical team accountable for market metrics and performance standards including use of HCBS review form and Time to Task Tool within Pathway application
- Promote individual development by providing learning and growth opportunities to clinical staff
- Communicate needs and issues addressed by clinical staff to local market and corporate leadership as appropriate
- Participate in site specific strategic planning activities
- Develop solutions to problems or barriers by partnering with key stakeholders including serving as liaison with Health Plan and DC Providers with Home & Community Based Services regarding utilization of long-term support and services resources
- Provide clinical operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)
- Serve as a role model to internal and external partners
- Oversee implementation and adoption of clinical and quality initiatives
- Use knowledge of the business and financial goals to determine and communicate clinical priorities
- Partner with staff to achieve business goals
- Monitor and hold clinical team accountable for Model of Care documentation
- Actively engage, coach and drive clinical staff in implementing activities to grow new membership
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:- Current unrestricted RN license in Washington DC
- 3+ years of related Utilization Management experience with focus on medical necessity reviews, compliance adherence, data analysis and managing and developing a team, preferably with specific Medicaid experience
- Proven experience in developing and sustaining internal and external client relationships with healthcare professionals
- Proficient computer skills, including the ability to document medical information with written and electronic medical records
- Valid Driver's License and Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area
- Willing or ability to up to 25-50% travel within Washington DC
Preferred Qualifications:- BSN
- Interqual or MCG certification or experience
- Certified Case Manager Certification (CCM)
- Knowledge of Medicare Dual (DSNP) and Medicaid environment
- Knowledge of Long-Term Services and Support (LTSS) and Home and Community Based Services (HCBS)
- Knowledge of managing complex medical conditions
- Proven solid business acumen including analysis and business planning experience
- Proven solid organizational skills and multitasking abilities will be keys to success
- Proven solid clinical critical thinking skills
- Proven excellent communication skills and demonstrated ability to foster a culture of clinical excellence and build collaborative relationships
- Must live within 50 miles for Washington DC
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 $91,700 - $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.
