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Field Case Manager RN (Monarch) - Irvine, CA
UnitedHealth Group • Irvine, CA
Posted 8 days ago
Are you ready for your next challenge? Discover it here at UnitedHealth Group and help us reinvent the health system. We're going beyond basic care, providing integrated health programs with a member - centric focus. The challenge is ensuring we deliver the right care at the right time. When you join us as a RN Nurseline Case Manager, you'll be making a difference in peoples' lives by offering telephonic support and assistance to members seeking health education, program referrals or general health services. You will work with patients to manage their health conditions for ultimate outcomes by taking in - bound calls and placing out-bound calls as dictated by consumer and business needs.
What makes your clinical career greater with UnitedHealth Group? You'll work within an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you'll open doors for yourself that simply do not exist in any other organization, anywhere. Whether in - person or over - the - phone, we're working to help others live healthier lives while providing an opportunity for you to do your life's best work.(sm)
***This is not an office based position. Candidate will travel to South Orange County to designated Nursing Homes and Long Term Care locations.
- Provides health education and coaches consumers on treatment alternatives to assist them in best decision making
- Supports consumers in selection of best physician and facility to maximize access, quality, and to manage heath care cost
- Coordinates services and referrals to health programs
- Prepares individuals for physician visits
- Assesses and triages immediate health concerns
- Manages utilization through education
- Identifies problems or gaps in care offering opportunity for intervention
- Assists members in sorting through their benefits and making choices
- Takes in - bound calls and places out - bound calls as dictated by consumer and business needs
- Special projects, initiatives, and other job duties as assigned
- Performs concurrent and retrospective onsite or telephonic clinical review at the designated network or out - of - network facilities as needed / directed by the Post - Acute Management team (Director, Manager, and Supervisors) documenting medical necessity and appropriate level of care utilizing clinical guidelines (e.g. Milliman, Interqual). Complies with CMS regulations and Health Plan requirements
- Interacts and effectively communicates with members, their families and / or designated member representative to assess discharge needs and formulate discharge plan, provide Health Plan benefit information, and services available based on clinical need
- Interacts daily with treating physicians regarding the Monarch HealthCare member's plan of care and alternative care solutions. Consults the Monarch Medical Director / designee for unusual and complex cases
- Effectively communicates plan of care to facility staff, health plan partners, and Ambulatory Case Management (ACM) to ensure understanding treatment plan and clinical needs at time of transition to lower level of care
- Efficiently navigates and utilizes computer data entry programs including, but not limited to: Microsoft Office (Outlook, Word, and Excel), RightFax, Adobe Reader for fax attachment process
- Provides guidance and benefits information for members and their families and facility discharge planners
- Documents and maintains a Continuity Plan of Care for the Monarch HealthCare member by assessing and identifying continued needs upon discharge to encompass; health services, durable medical equipment, hospice, follow - up physician appointments, skilled versus sub - acute versus custodial levels of care
- Issues the appropriate denial letters based on Health Plan or CMS guidelines utilizing ICE language
- Identifies and reports all institutionalized, ESRD and hospice patients, and appropriately refers members with special transition needs or disease management to ACM
- Performs on call duties as scheduled on a rotating basis
- Identifies Quality Improvement (QI) indicators and provides timely reporting to the QI department
- Actively participates in the orientation and ongoing training of new employees as needed
- Actively participates in the ongoing development of IPCS by participating in task forces for policy and procedure review / revision / development, staff meetings, and other departmental meetings / committees promoting Monarch HealthCare's core ideals and values
- Regular and consistent attendance
- Current, unrestricted RN licensure
- 3+ years of Clinical RN experience
- Strong inbound and outbound telephonic skills
- Intermediate computer skills (Microsoft Word, Outlook and Internet) with the ability to navigate a Windows environment and the ability to create, edit, save and send documents utilizing Microsoft Word
- Understanding of change and ability to move members along the continuum of change
- Intermediate or expert level of proficiency with being able to assess and identify needs and being able to influence and motivate
- Conflict management skills
- Able to work under pressure and appropriately prioritize responsibilities
- Bachelor's degree in Nursing
- Coaching and / or decision support experience
- Managed care experience
What happens when one of the most successful physician groups in Orange County comes together with a global leader in health care? Opportunity. With Monarch HealthCare joining Optum and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, quality care, and working together to improve the patient experience. It takes passion, commitment, focus and the ability to contribute effectively in a highly collaborative environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(sm)
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: Case Manager, RN, Irvine, CA, California