RN - Sr. Clinical Case Manager 2360234 | Albuquerque, NM

Health Care Innovation Opportunity

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

Positions in this function facilitates a team approach to ensure cost-effective delivery of quality care and services based on medical conditions and social determinants. Collaborates with members, providers, and other resources to assess, plan, implement, coordinate, monitor and evaluate options and services required to meet an individual's healthcare needs. Promotes member's goals for self management, facilitates effective health care system navigation, reduces gaps in care, and provides support and community resources as needed. Ensures compliance to contractual and service standards as identified by relevant health insurance plans. Adheres to policies, procedures and regulations to ensure compliance and patient safety.

Primary Responsibilities

• Role embedded within the primary care clinic, working directly with both clinical and non-clinical staff
• Conducts clinical evaluation of members per regulated timelines, determining who may qualify for complex case management based on clinical judgment, changes in member's health, social determinants, and gaps in care
• Creates and implements a case management plan in collaboration with the member, caregiver(s), provider(s), and/or other appropriate healthcare professionals to address the patient's needs and goals
• Performs ongoing updates of the care plan to evaluate effectiveness, and to document barriers, interventions, and goal achievement
• Partners with primary providers or multidisciplinary team members to align or integrate goals to plan of care
• Supports longitudinal care of the patient with chronic care conditions
• Supports transition of care from inpatient to outpatient setting
• Completes home, facility, clinic and telephonic visits for member engagement and enrollment
• Uses motivational interviewing to evaluate, educate, support, and motivate change during member contacts
• Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed
• Achieves Quality Measures outcomes via reduction in HEDIS Gaps in Care
• Performs accurate and timely documentation in the electronic medical record
• May perform clinical tasks within their scope of practice
• Ensures compliance with quality metrics specific to health plan delegation and accrediting body requirements
• Conducts self and peer audits
• Maintains caseload per defined medical management department standards
• Sustains productivity and audit requirements per medical management department standards
• Demonstrates ability to work independently and implement innovative approaches to complex member situations
• Sought out as expert and serves as leader/mentor to other members of medical management team
• Determines need for continued member management, creates care plan and facilitates transition to medical management programs
• Serves as facilitator and resource for other members of the Medical Group clinical team
• Attends departmental meetings and provides constructive recommendations for process improvement
• Performs other duties as assigned

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

• Associates Degree in Nursing
• Valid NM RN License or valid multi-state compact license
• Current BLS Certification
• 3+ years of job-related experience in a healthcare environment

Preferred Qualifications

• Bachelor's degree or higher in healthcare related field
• Case Management Certification
• 3+ years of experience providing case management and/or utilization review functions within health plan or integrated system

Knowledge/Skills/Abilities

• Excellent communication, interpersonal, organization and customer service skills
• Self-motivated, attention to detail
• Ability to multi-task and work under pressure
• Demonstrates knowledge of computer functionality and software applications (e.g., navigating systems, troubleshooting, electronic charting, accessing intranet and record management databases)
• Demonstrate knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, commercial) or regulatory bodies (e.g.,NCQA)
• Demonstrate understanding of relevant health care benefit plans

Physical Demands

• Rarely (Less than .5 hours/day)
• Occasionally (0.6 - 2.5 hours/day)
• Frequently (2.6 - 5.5 hours/day)

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 $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

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.