OVERVIEW OF POSITION:
Under the direction of a registered Nurse, this position is
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 basic 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 findings to the
Care Management department Supervisor / Manager / Director in a
Schedule: per diem, available weekends/holidays
Position can be remote
Care Management experience preferred
Consistently exhibits behavior and communication skills that
demonstrate Optum’s commitment to superior customer service,
including quality, care and concern with each and every internal
and external customer.
Implements current policies and procedures set by the Care
Conducts on-site or telephonic prospective, concurrent and
retrospective review of active patient care, including out-of-area
Reviews patients’ clinical records of acute inpatient assignment
within 24 hours of notification.
Reviews patients’ clinical records within 48 hours of SNF
Reviews patient referrals within the specified care management
policy timeframe (Type and Timeline Policy).
Coordinates treatment plans and discharge expectations.
Discusses DPA and DNR status with attending physician when
Prioritizes patient care needs. Meets with patients,
patients’ family and caregivers as needed to discuss care and
Acts as patient care liaison and initiates pre-admission
discharge planning by screening for patients who are high-risk,
fragile or scheduled for procedures that may require caregiver
assistance, placement or home health follow-up.
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 Optum
claims as necessary.
Attends all assigned Care Management Committee meetings and
reports on patient status a defined by the region.
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
Provides accurate information to patients and families regarding
health plan benefits, community resources, specialty referrals and
other related issues.
Initiates 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, date, etc.
Follows patients on ambulatory care management programs,
including CHF and home health, in order to optimize clinical
Uses, protects, and discloses Optum patients’ protected health
information (PHI) only in accordance with Health Insurance
Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
1 or 2 years of post-high school education or a degree from a
Graduation from an accredited school of Nursing.
Current California LVN license.
Over 1 year and up to and including 3 years of clinical
At least 1 year of recent clinical experience.
3 to 5 years of recent clinical nursing experience.
Previous care management, utilization review or discharge
Managed care experience.
KNOWLEDGE, SKILLS, ABILITIES:
Knowledge of current standards of patient care.
Thorough understanding of LVN 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.
Careers with Optum. Here's the idea. We built an entire
organization around one giant objective; make health care work
better for everyone. Optum, 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: Optum 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. Optum and its affiliated
medical practices is a drug-free workplace. Candidates are required
to pass a drug test before beginning employment.