Job Description

There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Nursing here isn't for everybody. Instead of seeing a handful of patients each day, your work may affect millions for years to come. Ready for a new path? Start doing your life's best work.(sm)

The Telephonic Care Manager (TCM) is responsible for utilization management and inpatient care management coordination in a telephonic care management position. The Care Manager will perform reviews of current inpatient services and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. The Care Manager works under the direct supervision of an RN or MD. This role acts as a support to team members, coaching, guiding and providing feedback as necessary. This function is responsible for care management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). The Telephonic Care Manager (TCM), LVN will act as an advocate for members and their families guide them through the Health Care system for transition planning. The function may also be responsible for providing health education, coaching and treatment decision support for members and will participate in interdisciplinary care conferences.

If you are located in Austin, Texas, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

* The TCM serves as the telephonic clinical liaison with hospital clinical and administrative staff as well as providing expertise for clinical authorizations for inpatient care.
* Makes outbound calls to assess members' current health status.
* Performs case reviews telephonically for assigned inpatient facilities and skilled nursing facilities. Advises supervisor of any potential problems as they become evident.
* Ensures that our members receive the proper levels of care based on evidence-based criteria and assesses and interprets needs and requirements, in addition to referring patients to disease or case management programs. Makes welcome home calls to ensure that discharged member receive the necessary services and resources according to transition plan.
* Conduct Utilization Reviews (concurrent and retrospective reviews) using approved health plan guidelines such as Milliman Criteria and/or InterQual Criteria.
* Demonstrate knowledge of utilization management processes and current standards of care as a foundation for utilization review and transition planning activities.
* Track ongoing status of all certification activity and maintain continuing certification (or denial).
* Makes telephonic assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers.
* Adhere to quality standards and state UR guidelines, as well as confidentiality of all information, policies, and procedures. Adheres to company policies, procedures, and reporting requirements.
* Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research.
* Performs all other related duties as assigned.
* Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department.

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:

* High School diploma or GED
* Current, unrestricted LVN license required, specific to the state of employment.
* 2 years of managed care and/or case management experience.
* 3 years of clinical experience
* Knowledge of managed care, medical terminology, referral process, claims and ICD-9 codes.
* Excellent verbal and written skills.
* Skills in planning, organizing, conflict resolution, negotiation and interpersonal skills to work with autonomy in meeting UM goals.
* Knowledge of utilization management and/or insurance review processes as well as current standards of care, a strong knowledge of health care delivery systems and the ability to interact with medical directors, physician advisors, clinicians and support staff.
* The ability to work independently in accomplishing assignments, program goals and objectives
* If you need to enter a work site for any reason, you will be required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or similar UnitedHealth Group-approved symptom screener. When in a UnitedHealth Group building, employees are required to wear a mask in common areas. In addition, employees must comply with any state and local masking orders

Preferred Qualifications:

* Case Management certification strongly desired.
* Proficient computer skills in Microsoft applications

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors., WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for 550,000+ older adults with over 16,000 doctors' offices 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)

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy

For more information on our Internal Job Posting Policy, click here.

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.