The Transition Care Manager is responsible for utilization management and inpatient care management coordination and will perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services by following medical guidelines and benefit determination. They will also identify, screen, track, monitor and coordinate the care of members with multiple co-morbidities, psychosocial needs, transition needs and develop a nursing plan of care as well as prospective, concurrent, and retrospective utilization review of inpatient services. The Transition Care Manager acts as an advocate for members and their families by linking them to other members of the care team to help them gain knowledge of their disease process and to identify community resources for continued growth toward the maximum level of independence. The Transition Care Manager is responsible for the case management activities across the continuum of care including coordination of care, medical management consulting and may also provide health education, coaching and treatment decision support for members. The Transition Care Manager participates in interdisciplinary conferences and Patient Care Coordination Meeting (PCC) to review clinical assessments, update care plans and determine follow-up frequency with the team.
Essential Job Functions
- Collaborates effectively with interdisciplinary team (IDT) to establish an individualized plan of care for members. The interdisciplinary care team Develops interventions to assist the member in meeting short and long term plan of care goals.
- Serves as the clinical liaison with hospital, clinical and administrative staff as well as provides expertise for clinical authorizations for inpatient care. based on utilized evidenced-based criteria
- Assess and evaluate new admissions and determines appropriate level of care based on evidenced-based criteria as well as monitors daily in-patient census for accuracy.
- Stratifies and/or validates patient level of risk and communicates during transition process with IDT
- Provide assessments of physical, psycho-social and transition needs in settings not limited to the PCP office, hospital, or member's home. Develops interventions and processes to assist the Health Plan and/or MSO member in meeting short and long term plan of care goals.
- Coordinates and attends member visits with PCP and specialists as needed.
- Manages assigned case load in an efficient and effective manner utilizing time management skills to facilitate the total work process directly monitoring assigned members
- Provides constructive information to minimize problems and increase customer satisfaction.
- Seeks ways to improve job efficiency and makes appropriate suggestions following the appropriate chain of command.
- Demonstrates knowledge of utilization management and care coordination processes and current standards of care as a foundation for transition planning activities.
- Confers with physician advisors on a regular basis regarding inpatient cases and participates in departmental utilization rounds. Plans member transitions, with providers, patient and family.
- Enters timely and accurate data into designated care management applications as needed to communicate patient needs and maintains audit scores of 90% or better on a quarterly basis.
- Adheres to organizational and departmental policies and procedures and credentialed compliance.
- Takes on-call assignment as directed.
- Attends and Participates in interdisciplinary team meetings as directed
- Problem solving by gathering and /or reviewing facts and selecting the best solution from identified alternatives. Decision-making is usually based on prior practice or policy, with some interpretation. Must apply individual reasoning to the solution of problems, devising or modifying processes and writing procedures as necessary.
- Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms.
- With the assistance of the Managed Care/UM teams, guides physicians in their awareness of preferred contracts and providers and facilities.
- Participates in the development of appropriate QI processes, establishing and monitoring indicators.
- Performs all other related duties as assigned
- Bachelor's degree in Nursing, or Associate's degree in Nursing and Bachelor's degree in related field, or Associate's degree in Nursing combined with 4 or more years of experience.
- Current, unrestricted RN license required, specific to the state of employment.
- Case Management Certification (CCM) or ability to obtain CCM within one year of employment.
- Three or more years of diverse clinical experience in caring for the acutely ill patients with multiple disease conditions.
- Two or more years of managed care and/ or case management experience.
- Knowledge of utilization management, quality improvement, discharge planning, and cost management.
- Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
- Proficient with Microsoft Office applications including Word, Excel, and Power Point.
- Independent problem identification/resolution and decision making skills.
- Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
Preferred Education, Experience & Skills
- Experience working with psychiatric and geriatric patient populations.
- Bilingual (English/Spanish) language proficiency.
Physical & Mental Requirements
- Ability to lift up to 50 pounds
- Ability to push or pull heavy objects using up to 25 pounds of force
- Ability to sit for extended periods of time
- Ability to use fine motor skills to operate office equipment and/or machinery
- Ability to receive and comprehend instructions verbally and/or in writing
- Ability to use logical reasoning for simple and complex problem solving
WellMed is a healthcare delivery system serving more than 90,000 patients, primarily Medicare eligible seniors, in Texas and Florida through primary care clinics, multi-specialty clinics, and contracted medical management services. Headquartered in San Antonio, Texas, WellMed is an industry leader in medical risk management, highly effective disease management and chronic care programs, healthcare delivery services and more.
Our focus and mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. We are innovators in preventative healthcare, striving to change the face of healthcare delivery for seniors. Our providers and support staff are selected for their dedication to the senior population and focus on preventative, proactive patient care.
WellMed is now part of the OptumHealth division under the greater UnitedHealth Group umbrella.
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.
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