OVERVIEW OF POSITION:
Responsible for ensuring the continuity of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing advanced nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site or telephonically as the need arises. Reports finding to the Care Management department Supervisor / Manager / Director in a timely manner.
Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Implements and monitors current medical group care management programs within the policies and procedures set by the Care Management department.
Conducts on-site or telephonic prospective, concurrent and retrospective review of active patient care, including out-of-area and transplant.
Reviews patients’ clinical records of acute inpatient within 24 hours of notification.
Reviews patients’ clinical records within 48 hours of SNF admission.
Reviews patient referrals within the specified care management policy timeframe (Type and Timeline Policy).
Coordinates treatment plans and discharge expectations and discusses DPA and DNR status with attending physician.
Prioritizes patient care needs and meets with patients, patients’ family and caregivers as needed to discuss care and treatment plan.
Identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings.
Consults with physician and other team members to ensure that care plan is successfully implemented.
Coordinates provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.
Communicates authorization or denial of services to appropriate parties. Communication may include patient (or agent), attending/referring physician, facility administration and HCP claims as necessary.
Participates actively in assigned Care Management Committee (CMC) meetings. Documents pertinent patient information, all communication and CMC decisions.
Demonstrates a thorough understanding of the cost consequences resulting from care management decisions through utilization of appropriate reports such as Health Plan Eligibility and Benefits, Division of Responsibility (DOR) and Bed Days.
Ensures appropriate utilization of medical facilities and services within the parameters of the patients’ benefits and/or CMC decisions. This includes appropriate and timely movement of patients through the various levels of care.
Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients and families.
Provides accurate information to patients and families regarding HMO benefits, community resources, referrals and other related issues.
Initiates and oversees data entry into IS systems of all patients within the parameters of care management policies and procedures.
Maintains accurate and complete documentation of care rendered including LOC, CPT code, ICD-9, referral type and date.
Follows patients on ambulatory care management programs, including CHF and home health in order to optimize clinical outcomes.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
Bachelor’s degree from a four-year college and/or a professional certification requiring formal education beyond a two-year college.
Graduation from an accredited school of Nursing.
California RN license.
Bachelor’s degree in Nursing preferred.
Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross).
Over 3 years and up to and including 5 years of experience.
At least 1 year of recent clinical experience.
3 to 5 years of acute nursing experience in critical care.
Previous care management, utilization review or discharge planning experience.
KNOWLEDGE, SKILLS, ABILITIES:
Ability to type 25 wpm.
Knowledge of current standards of patient care.
Thorough understanding of RN scope of practice.
Manual dexterity to use/handle equipment and instruments.
Ability to effectively communicate and collaborate with physicians, patients, families and ancillary staff.
Ability to make sound, independent judgments and act professionally under pressure.
What's the first thing that happens when one of the leading independent medical groups in the country comes together with a global leader in health care? Opportunity. With DaVita Medical Group, HealthCare Partners, The Everett Clinic, Northwest Physicians Network, MountainView Medical Group and Magan Medical Clinic joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. We're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(SM)
Careers with OptumCare. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health - related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. OptumCare, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM)
Diversity creates a healthier atmosphere: OptumCare and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers 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. OptumCare and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.