Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)
The Telephonic Care Manager (TCM) is responsible for utilization management and inpatient care management coordination in a telephonic care management position. The Care Manager will perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. The Care Manager works under the direct supervision of an RN or MD. This role acts as a support to team members, coaching, guiding and providing feedback as necessary. This function is responsible for care management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). The Telephonic Care Manager (TCM), LVN will act as an advocate for members and their families guide them through the Health Care system for transition planning. The function may also be responsible for providing health education, coaching and treatment decision support for members and will participate in interdisciplinary care conferences.
***Must reside in Houston, TX***
Serves as the telephonic clinical liaison with hospital clinical and administrative staff as well as providing expertise for clinical authorizations for inpatient care
Makes outbound calls to assess members' current health status
Performs case reviews telephonically for assigned inpatient facilities and skilled nursing facilities
Advises supervisor of any potential problems as they become evident
Ensures that our members receive the proper levels of care based on evidence-based criteria and assesses and interprets needs and requirements, in addition to referring patients to disease or case management programs
Makes "welcome home" calls to ensure that discharged member receive the necessary services and resources according to transition plan
Conduct Utilization Reviews (concurrent and retrospective reviews) using approved health plan guidelines such as Milliman Criteria and/or InterQual Criteria
Demonstrates knowledge of utilization management processes and current standards of care as a foundation for utilization review and transition planning activities
Tracks ongoing status of all certification activity and maintain continuing certification (or denial)
Makes telephonic assessments regarding patient treatment plans and establish collaborative relationships with physician advisors, clients, patients, and providers
Adheres to quality standards and state UR guidelines, as well as confidentiality of all information, policies, and procedures
Adheres to company policies, procedures, and reporting requirements
Maintains in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research
Performs all other related duties as assigned
Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department
This person will need to make visits to patient's homes and clinics as needed (up to 25% of the time, once these visits resume). This person will be able to work from home and telecommute.
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
High school diploma / GED
Current, unrestricted Texas LVN license or Compact license
3+ years of clinical experience
2+ years of managed care and/or case management experience
Knowledge of managed care, medical terminology, referral process, claims and ICD-9 codes
Knowledge of utilization management and/or insurance review processes as well as current standards of care, solid knowledge of health care delivery systems and the ability to interact with medical directors, physician advisors, clinicians and support staff
This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor’s diagnosis of disease
Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation
Case Management certification
Proficient computer skills in Microsoft applications
Ability to work independently in accomplishing assignments, program goals and objectives
Skills in planning, organizing, conflict resolution, negotiation and interpersonal skills to work with autonomy in meeting UM goals
Excellent verbal and written skills
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.
*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.