Senior Complex Case Manager

UnitedHealth Group
United States, New Mexico, Albuquerque
Nov 26, 2024
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 Identifies and considers 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 on a regular and assigned timeline 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/preceptor 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 New Mexico RN License or valid multi-state compact license Current BLS Certification 3+ years of previous job-related experience in a healthcare environment Experience utilizing excellent communication, interpersonal, organization and customer service skills Demonstrated ability to multi-task and work under pressure Demonstrated knowledge of computer functionality and software applications (e.g., navigating systems, troubleshooting, electronic charting, accessing intranet and record management databases) Demonstrated knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, commercial) or regulatory bodies (e.g., NCQA) Demonstrated understanding of relevant health care benefit plans 21+ years or older and hold a valid New Mexico State Driver's license 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