SUMMARY: To perform a member centric process that assesses, plans, coordinates, implements, monitors and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes.
Care Team Nurses are responsible for the identification, evaluation and coordination of all health care services provided to a select managed care population to manage the continuum of care, i.e. authorizations, referrals to complex case management, disease management and any other appropriate services required for total care of the enrollees' health care needs. Nurses are also responsible for providing relevant and measurable outcomes to the administration, Management Committees and contracted Health Plans.
The Integrated Care Team (ICT) is an approach characterized by a high degree of collaboration and communication among health professionals, sharing of information among team members related to patient care and the establishment of a comprehensive treatment plan to address the biological, psychological, and social needs of the patient. Monarch HealthCare Integrated Care Teams are assigned by geographical areas, age specific populations, lines of business and risk groups.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Review referrals and authorizations following established policies and procedures in accordance with nationally recognized standards.
2. Process referrals using online system, evidence based guidelines and criteria hierarchy from CMS and health plans.
3. Coordinate health care services with appropriate physicians, facilities, contracted providers, ancillary providers, allied health professionals, funding sources and community resources.
4. Develop and maintain effective working relationships, with physicians and office staff of the ICT.
5. Act as liaison between member, Care Team and MHC Medical Directors.
6. Coordinate out-of-network and out-of-area cases with member, Health Plans and Clinical Services and the Care Team.
7. Provide alternative health care services utilizing contracted ,community and internal services/programs.
8. Participate in patient case review, IDT meetings and case rounds as requested.
9. Maintain comprehensive and confidential case files.
10. Utilize clinical knowledge to apply any/all MHC approved evidence-based practice guidelines and criteria.
11. Maintain confidentiality of all member information and MHC business.
12. Present as a professional representative of MHC
13. Perform additional duties/tasks as assigned by the Lead, Supervisors and Manager.
14. Maintain and comply with all MHC policies and procedures.
15. Attend in-services, training and meetings relating to job tasks as directed and required.
16. Regular and consistent attendance.
EDUCATION and/ or EXPERIENCE:
* Graduate of an accredited School of Nursing, RN
* Current, valid and unrestricted license to practice in the Sate of CA
* BSN or equivalent desirable
* Minimum of 3 years recent acute care or managed care experience desirable
LANGUAGE SKILLS: Ability to read and analyze, interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports and business correspondence. Ability to effectively present information, respond to questions from managers, clients, customers and the general public.
MATHEMATICAL SKILLS: Ability to work with mathematical concepts and the ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
* 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.
* BSN or equivalent preferred.
* Must possess and maintain a current and valid California Driver's License.
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 of 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.
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 imagined.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.
Skills / Requirements
Monarch HealthCare - 12 months ago