The On-Site RN Case Manager is responsible for discharge planning, improved transitions of care, and utilization management of hospitalized health plan members. Ensure they receive quality medical care in the most appropriate setting. Performs the following case management skills on a daily basis: 1) perform patient assessment of all major domains using evidence based criteria (physical, functional, financial and psychosocial); 2) develop individualized discharge plans that involve provider, patient, and caregiver goals for successful transitions of care.; 3) implement discharge plan involving health care resources across the continuum; and 4) monitor and report variances that may challenge timely quality care.
**This position will be on-site at Summerlin Hospital**
Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care.
Utilize both company and community based resources to establish a safe and effective case management plan for hospitalized members.
Collaborate with patient, family, and health care providers to develop an individualized plan of care that encompasses both acute care episode and post hospital discharge plan.
Communicate with all stakeholders the required health related information to ensure quality coordinated care and services are provided expeditiously to all hospitalized members.
Advocate for patients and families as needed to ensure the patient's needs and choices are fully represented and supported by the health care team.
Utilize approved clinical criteria to assess and determine appropriate level of care for hospitalized members.
Understand insurance products, benefits, coverage limitations, insurance and governmental regulations as it applies to the health plan.
Accountable to understand role and how it affects utilization management benchmarks and quality outcomes. .
Must possess an active and current Nevada RN license
2+ years of varied clinical experience in a hospital setting with an emphasis on case management or utilization management (Med/Surg background is helpful and preferred)
Possess knowledge of utilization management in a managed care environment.
Demonstrate initiative toward problem solving without direct supervision.
Strong organizational and computer skills.
Electronic Medical Records (EMR) experience a Must. (will be working with various systems).
Strong written and oral communication skills.
Good problem-solving skills.
Assess patient needs to coordinate appropriate level of care.
Ability to negotiate with professionals, patients, and caregivers.
Independent case management knowledge and skills to formulate plans of care without direct supervision.
Case management experience preferred.
Bachelors in nursing preferred
CCM preferred or willing to obtain within 2 years of employment
Knowledge of Interqual or Milliman guidelines preferred.
Experience in a managed care organization preferred.
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UnitedHealth Group - 15 months ago
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