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The Manager of Case Management Services is responsible for the supervision, evaluation and direction of the Utilization Compliance and Quality Management process. The position will ensure compliance with the case management program for prospective, concurrent, retrospective and transition to out-patient care coordinating with physicians, hospitals and ancillary care and empowers team members through active problem solving and resource direction. The position is a resource for difficult or complex case management or discharge planning. The manager successfully impacts assigned team and organization by mentoring those who wish advancement and engages in departmental process improvement teams and activities. In addition, the Case Management Manager is responsible for timely completion of documentation audits, and reviewing and mentoring team members to meet and exceed all documentation compliance standards. This position mentors and trains case managers in the completion of timely, accurate monthly reconciliation reports and statistics and functions as an advisor to Physicians and lower-level utilization management staff.
- Displays decision making based on prior practices or policy, with some interpretation
- Solves problems and/or reviews facts and selects the best solution from identifying alternatives with the ability to apply individual reasoning to the solution of a problem and identifies and reports processes or procedures that require modification
- Provides assistance with orientation and mentoring of new case managers
- Reviews difficult and/or exceptional preauthorization requests
- Ensures the identification or potential early discharge to reduce LOS or prevent hospital admissions
- Regular attendance at PCC in assigned region, mentoring lower-level case managers; reviews referrals prior to PCC, assists with complicated referral requests and assists with concerns and benefit application
- Manages difficult, complex and catastrophic patients
- Offers resourceful planning of alternative services when a specific setting or service is not available in the admission facility when approached by assigned team members
- Attends and contributes to strategic planning meetings at assigned team clinics as well as to departmental processing improvement meetings
- Oversees telephonic case management staff and UM outpatient care coordination staff and ensures compliance with approved standardized guidelines, regulations and contractual agreements
- Monitors employees for excessive work and inability to complete position responsibilities within a normal workday and provide time management advice to employees that are unable to complete position responsibilities
- Takes ownership of the total work process and provides constructive information to minimize problems, increase customer satisfaction and improve job efficiency. Makes suggestions to appropriate managers as well as participates in the budgeting process by informing the manager of capital and operating needs
- Maintains and stores supplies and equipment in a safe manner to eliminate/reduce safety risks
- Strives to personally expand working knowledge of all aspects of WellMed departments
- Attends educational offerings to keep abreast of changes and comply with licensing requirements
- Conducts annual evaluations of team members in a timely basis; provides feedback in a constructive manner and respects the confidentiality of personnel issues
- Participates in UM/quality improvement committees and conducts special UM/QI studies as necessary
- Customer Service
- Liaison to market providers for UM providers
- Fosters discharge plan collaboration with patient/family, attending physician and facility Case Manager
- Performs all duties to customers in a prompt, pleasant, professional and responsible manner regardless of the stressful nature of the situation and always identifies self by name and title
- Guides and answers benefit questions, contract issues, and updates physicians/medical groups of preferred contracts, providers, facilities and hospital utilization and noncompliance issues
- Completes Case Management Documentation System (CMDS) audits on a monthly basis to maintain CMDS entry, compliance with bed, day, and financial responsibility information on in-patient admissions
- Educates medical services personnel regarding utilization management policies, procedures and techniques
- Oversees case managers and ensures compliance with approved standardized guidelines, regulatory requirements and contractual agreements while respecting the confidentiality of these agreements
- Demonstrates thorough knowledge of health plan benefits and quality of care criteria of health plan as well keeping abreast and compliance with established and all new or revised WellMed policies and procedures when posted or distributed with accurate interpretation to customers
- Mentors new employees and provides orientation as well as assists in the growth and development of associates by sharing special knowledge with others and trains and shares information with less experienced case managers to improve performance and outcomes of patient services
- Supports the continuing education of assigned team with documentation compliance into the CMDS
- Analyzes and reports aberrant utilization trends and plans intervention
- Supervises daily UM processes and assigns tasks and projects according to workflow volume and requirements of the UM program
- Assists with interviews, new employee selection and training for open positions and collaborates with all managers in placing candidates in the appropriate positions
- Assesses and evaluates staff performance annually and assists in developing their skills with the goal of reaching highest aptitude for position and career goals
- Coaches and counsels staff with performance concerns that require process improvement plans including monitoring and coaching for improved outcomes in collaboration with manager
This is an office base position near Corporate Centre Blvd., close to Lee Vista Blvd.
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.
- Professional Nursing Degree with current RN License (in state of employment)
- 5+ years of experience in medical or ICU hospital-based nursing or case management, discharge planning, utilization review or other cost containment role
- 1+ years of supervisory, team leader, or charge nurse experience required or 1+ year of successful case management experience with WellMed
- Working knowledge of the managed care referral process, case management, claims, contracting, and physician practice
- Medicare criteria knowledge
- Sound knowledge of NCQA and federal regulations
- Solid critical thinking, written and verbal interpersonal communication skills with ability to interact with professional and non-professional staff regarding healthcare issues
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.
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.
Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers 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.
OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.