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　　Positions in this function facilitates a team approach to ensure cost-effective delivery of quality care and services based on medical conditions and social determinants. Collaborates with members, providers, and other resources to assess, plan, implement, coordinate, monitor and evaluate options and services required to meet an individual’s healthcare needs. Promotes member’s goals for self management, facilitates effective health care system navigation, reduces gaps in care, and provides support and community resources as needed. Ensures compliance to contractual and service standards as identified by relevant health insurance plans. Adheres to policies, procedures and regulations to ensure compliance and patient safety.

　　Primary Responsibilities:

　　Conducts clinical evaluation of members per regulated timelines, determining who may qualify for complex case management based on clinical judgment, changes in member's health, social determinants, and gaps in care

　　Creates and implements a case management plan in collaboration with the member, caregiver(s), provider(s), and/or other appropriate healthcare professionals to address the patient’s needs and goals

　　Performs ongoing updates of the care plan to evaluate effectiveness, and to document barriers, interventions, and goal achievement

　　Partners with primary providers or multidisciplinary team members to align or integrate goals to plan of care

　　Completes home, facility, clinic and telephonic visits for member engagement and enrollment

　　Uses motivational interviewing to evaluate, educate, support, and motivate change during member contacts

　　Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed

　　Ensures compliance with quality metrics specific to health plan delegation and accrediting body requirements

　　Conducts self and peer audits

　　Maintains caseload per defined medical management department standards

　　Sustains productivity and audit requirements per medical management department standards

　　Demonstrates ability to work independently and implement innovative approaches to complex member situations

　　Sought out as expert and serves as leader/mentor to other members of medical management team

　　Determines need for continued member management, creates care plan and facilitates transition to medical management programs

　　Serves as facilitator and resource for other members of the Medical Group clinical team

　　Attends departmental meetings and provides constructive recommendations for process improvement

　　Performs other duties as assigned

　　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.

　　Required Qualifications:

　　Associates Degree in Nursing

　　Valid NV RN License

　　Current BLS Certification

　　3+ years of previous job-related experience in a healthcare environment

　　Preferred Qualifications:

　　Bachelor’s degree or higher in healthcare related field

　　Case Management Certification

　　3+ years of experience providing case management and/or utilization review functions within health plan or integrated system

　　Knowledge/Skills/Abilities:

　　Excellent communication, interpersonal, organization and customer service skills

　　Self-motivated, attention to detail

　　Ability to multi-task and work under pressure

　　Demonstrates knowledge of computer functionality and software applications (e.g., navigating systems, troubleshooting, electronic charting, accessing intranet and record management databases)

　　Demonstrate knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, commercial) or regulatory bodies (e.g.,NCQA)

　　Demonstrate understanding of relevant health care benefit plans

　　Physical Demands :

　　Rarely (Less than .5 hours/day)

　　Occasionally (0.6 - 2.5 hours/day)

　　Frequently (2.6 - 5.5 hours/day)

　　Nevada Residents Only: The salary range for Nevada residents is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

　　At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission .

　　Diversity creates a healthier atmosphere: OptumCare is an 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 is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.