RN Utilization Management (Per Diem)

Healthcare Partners Chatsworth , GA 30705

Posted 2 months ago

OVERVIEW:

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. Works in conjunction with the care team and PCP as care team leader. Ensures evaluation is in alignment with site based goals.

ESSENTIAL FUNCTIONS:

  • 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.

  • Prioritizes patient care needs upon initial visit and addresses emerging issues.

  • 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 treatment plans with the care team and triages interventions appropriate to the skill set of the team members.

  • Uses protocols and pathways in line with established disease management and care management programs and approved by medical management in order to optimize clinical outcomes.

  • Monitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-management.

  • Oversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., in order to maintain continuity of care.

  • Works in coordination with the care team and demonstrates accountability with patient management and outcome.

  • Discusses Durable Power of Attorney (DPoA) and advanced directive status with PCP when applicable.

  • Maintains effective communication with the physicians, hospitalists, extended care facilities, patients and families.

  • Provides accurate information to patients and families regarding HMO benefits, community resources, referrals and other related issues.

  • Participates actively in assigned Care Management Coordination Committee (CMCC) meetings.

  • Documents pertinent patient information and Care Management Plan in Electronic Health Record and Care Management Systems as appropriate.

  • Coordinates care with central departments on assigned patient caseload, including out-of-area, inpatient central and transplant.

  • Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization of reports and systems such as Health Plan Benefits, Division of Financial Responsibility (DOFR), utilization of metrics and CM reports.

  • Adheres to departmental policies and procedures as approved by Office of the Medical Director (OMD) Quality Committee.

  • 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.

EDUCATION:

  • 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).

EXPERIENCE:

Minimum:

  • Over 3 years and up to and including 5 years of experience in clinical setting demonstrating the ability to assess, document and implement the nursing care plan.

  • Past clinical experience.

Preferred:

  • 3 to 5 years of acute nursing experience in critical care.

  • Previous care management, utilization review or discharge planning experience.

  • HMO experience.

KNOWLEDGE, SKILLS, ABILITIES:

  • Computer literate.

  • 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.

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.


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RN Utilization Management (Per Diem)

Healthcare Partners