Manager RN Case Management Harlingen Texas

WellMed, part of the Optum family of businesses, is seeking a Registered Nurse to join our team in Harlingen, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

The Manager of Case Management is responsible for facilitating communication and directing the operations of all Case Management programs in a defined market. The Manager leads the market staff on all activities related to medical management initiatives including changes in process, staffing or care delivery model.. Additionally, the manager ensures compliance with all state/federal regulations and NCQA/URAC standards. The Manager collaborates with the Regional Director of Case Management, medical directors, PCPs, clinic and corporate medical management leadership on care coordination activities.

Primary Responsibilities:

• Supports case management operations across the continuum of care (assessing, planning, implementing, coordinating, monitoring, and evaluating)
• Oversees care management functions and ensure compliance with application of criteria from approved standardized guidelines, government mandated regulations and contractual agreements, to include NCAQ, URAC, and CMS
• Engages in Care Team forums/meetings to support care coordination activities between the market providers and the case management team
• Plans, organizes and oversees staff to ensure timely completion of um determinations, discharge planning and case management assessments
• Ensures team meets established performance metrics and medical cost reduction goals. Includes timely reporting of monthly KPIs
• Adapts departmental plans and priorities to address business and operational challenges
• Oversees the team’s daily staffing requirements to meet program standards
• Implements and interprets organizational policies and procedures, reviews work of staff to ensure that policies and guidelines are appropriately applied.
• Tracks and trends outcomes for potential improvements in the care management process. Creates monitors, evaluates and disseminates program and productivity reports weekly, monthly, and as needed
• Interviews, hires, and retains staff to meet the needs of the department
• Evaluates staff performance and recommend merit increases, promotions, and disciplinary actions
• Attends, and assists with the facilitation of local market intra-disciplinary care team meetings
• Monitors and oversees the reporting of all quality issues to medical management leadership for referral and reporting to health plans as appropriate
• Monitors appropriate utilization of resources, overtime, supplies and mileage
• Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations
• Performs all other related 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:

• Bachelor of Science in Nursing (BSN) (Four additional years of experience beyond the required years of experience may be substituted in lieu of a bachelor’s degree)
• Current unrestricted RN license in the applicable state 
• CCM certification or proof that certification has been obtained within one year of hire date
• 5+ years of healthcare experience to include experience in a managed care setting, hospital setting and/or physician practice setting 
• 3+ years of demonstrated supervisory or management experience with responsibility for team performance management
• Solid experience with MS office including Word, Excel and Outlook with proficient ability to navigate in a Windows environment
• Ability to establish and maintain effective working relationships with employees, managers, healthcare professionals, physicians and other members of senior administration and the general public
• Data mining, analytical and reporting skills. Ability to review and interpret data to make recommendations to senior-management
• Solid organizational skills and multitasking abilities
• Ability to travel in and /or out-of-town as deemed necessary by business need

Preferred Qualifications:

• Master’s Science in Nursing
• Prior multi-site regional operations management responsibility 

Physical & Mental Requirements:  

• Ability to sit for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing 
• Ability to use logical reasoning for simple and complex problem solving

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we’re making health care work better for everyone.

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.