SUMMARY: Disease Management is the concept of managing healthcare costs, improving or maintaining quality of life for individuals with chronic disease conditions by preventing or minimizing the effects of that condition through integrative care in large populations. It is a collaborative process that is concerned with common chronic illness and the reduction of future complications by educating self management concepts.
Nurses are responsible for the identification, evaluation and coordination of chronic care management and reporting outcomes to the ACM/DM Manager, Management Committees and contracted HealthPlans.
DEFINITION: Disease Management is defined as a Monarch HealthCare (MHC) established program that assists in the delivery of quality care to enrolled patients in the support of self management by health coaching. They include, but are not limited to, coronary heart disease, heart failure, diabetes, asthma, COPD, and other common conditions.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. Manage a case load of select patients with chronic diseases following established protocols and systems for disease management in collaboration with physicians and specialty services.
2. Review all referrals and authorizations associated with the cases in accordance with MHC and NCQA Standards.
3. Coordinate health care services with appropriate physician(s), facility(ies), contracted providers, and ancillary provider(s), (HealthCare Team).
4. Provide HealthCare Team members and Health Plans with referrals and/or authorizations as required.
5. Maintain comprehensive and confidential case files.
6. Provide any/all MHC Committees with comprehensive summary of all active DM cases as required.
7. Collect and analyze health services data for the purpose of monitoring, tracking and trending.
8. Provide data for trending of emergency care utilization for physician and member education.
9. Maintain confidentiality of all member information and MHC business.
10. Refer members to appropriate health plan, State or Federal Disease/Condition Management programs.
11. Act as resource for department staff, inter-departmental staff, contracted physicians, Health Plans, contracted facilities, members/families and ancillary providers.
12. Assist with the evaluation and revision of DM policy and procedures.
13. Present as a professional representative of Monarch HealthCare.
14. Perform additional duties/tasks as assigned by the supervisor and/or designee.
15. Attend in-services, training and meetings relating to job tasks as directed and required.
16. Regular and consistent attendance.
What makes your clinical career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You can work with in 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.
SUPERVISORY RESPONSIBILITIES: Assist with the supervision of the Disease Management Care Coordinator relating to daily workflow, program operations, and processes.
QUALIFICATION To perform this job successfully, an individual must be able to perform each essential duty. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE: Current and valid, unrestricted California state nursing license. Successful completion of an approved Nurse Practitioner program with current approval by the joint Board of Medical Examiners and Board of Registered Nursing to perform medical acts. Current Certified Case Manager (CCM) preferred.
OTHER SKILLS AND ABILITIES: Excellent verbal and written communication skills. Good to excellent computer skills. Self-motivated with effective critical thinking skills. Ability to work collaboratively as part of the Disease Management department team and all other areas providing member services or support. Thorough knowledge of managed care, third party payers, regulatory requirements and government entitlement programs. Excellent telephonic etiquette. Ability to multi-task and set priorities. Able to work independently.
LANGUAGE SKILLS: Analyze, and interpret job related scientific and technical journals, financial and data reports and legal documents. Respond effectively verbally and in writing to inquiries or complaints from customers, regulatory agencies or members of the business community. Communicate assertively as well as collaboratively with Management, staff, health plans, physicians, and patients. Effectively present information to Management team. Bilingual desirable.
MATHEMATICAL SKILLS: Apply concepts such as fractions, percentages, ratios and proportions to practical situations. Read and interpret daily department reports that include raw data, trends displayed in graphs. Explain, share and use this data with all staff members.
REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to set priorities, define and implement effective workflow and processes.
CERTIFICATES, LICENSES, REGISTRATIONS: Current and valid, unrestricted, California Registered Nursing (RN) license. Current Certified Case Manager (CCM) preferred. Certification for Disease Management desired. BSN or equivalent preferred. Must possess and maintain a current and valid California Driver's License.
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel objects, tools, or controls and talk or hear. The employee frequently is required to sit and reach with hands and arms. The employee is occasionally required to stand and walk.
The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision.
WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.
OptumHealth is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
OptumHealth helps nearly 60 million Americans live their lives to the fullest by educating them about their symptoms, conditions and treatments; helping them to navigate the system, finance their health care needs and stay on track with their health goals. No other business touches so many lives in such a positive way. And we do it all with every action focused on our shared values of Integrity, Compassion, Relationships, Innovation & Performance.
At OptumHealth, you will perform within an innovative culture that's focused on transformational change in the health care system. You will leverage your skills across a diverse and multi-faceted business. And you will make contributions that will have an impact that's greater than you've ever
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