Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life's best work.(sm)
The Inpatient LVN Case Manager is responsible for managing for the facilitation of the inpatient Utilization Management process including in-network, out of network, case management and discharge planning, along with assisting the Associate Director of Inpatient Management with UM/QM functions as necessary. Acts as a facility liaison to promote cooperation and efficiency between the IPA and the facility.
- Directly performs concurrent review
- Accurately identifies and documents level of care
- Coordinates, facilitates and documents comprehensive discharge planning
- Coordinates in-network services for OON discharges
- Ensures the appropriate utilization of capitated and contracted specialists, providers, facilities, and vendors according to region and risk
- Attends inpatient review rounds and presents cases to medical director(s), health plans and ACMM management staff
- Facilitates OON transfers to In-Network facilities
- Works collaboratively with internal and hospital contract staff:
- Initiates letter of agreement for OON services in a timely manner
- Provides input for potential contracts
- Identifies and communicates high dollar / high risk cases
- Oversees the utilization of contracted facilities and reports OON utilization
- Develops and maintains relationships with both network and Out of Network hospital UM and ER staff
- Works directly with AppleCare Hospitalists to develop and implements inpatient processes including, but not limited to:
- Identification of patients and referral to specialty clinics such as Comprehensive Care (high-risk) Clinic, Anti-coagulation and/or Diabetic Clinic
- Facilitates and ensures timely communication between PCP and Hospitalists
- Provides direct Case Management activities if necessary
- Identifies readmit for CM coordinations
- Identifies Healthy Families and Medi-Cal members for CCS referral and facilitates those referrals
- Identifies and coordinates high dollar/high risk patients to case management
- Participates in UMC/QIC, PCP, Provider Office Meetings, health plan JOMs, and hospital JOCs as assigned
- Participates in inpatient UM/QM projects and completes in a thorough and timely manner
- Other duties as assigned which may include weeknight, weekend, and holiday on-call
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 or GED
- Current and unrestricted LVN license for the state of California
- 2+ years of experience in a managed care environment, SNF, IPA or MSO. Other case management experience will be considered
- Basic level of experience with Microsoft Word, with the ability to navigate a Windows environment
- 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 (CCM)
- Bilingual Spanish speaking (ability to read, write, speak)
- Knowledge of and experience with the utilization of UM criteria such as Milliman & Robertson, Medicare and Medicaid guidelines, health plan criteria, etc
- Knowledge of standardized CMS, Medicare Advantage, HMO, and Medi-Cal benefits structures
- Knowledge of HMO, MSO, and ACO structures and operations
- Thorough clinical knowledge of common inpatient diagnoses
- Understanding of DRGs
- Ability to perform complex problem soling
- Ability to work effectively with physicians
- Solid people skills
- Solid Microsoft office Word, Excel and internet skills
- Solid organizational 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 Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.
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: 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.