Case Manager - Registered Nurse - Remote

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. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.  

The Care Manager - Registered Nurse provides ongoing support and expertise through comprehensive assessment, planning, implementation, and overall evaluation of individual member needs.  The goal of this position is to enhance the quality of member management and satisfaction, to promote continuity of care and cost effectiveness through the integration and functions of care management and discharge planning.  It is the purpose of the Care Manager - Registered Nurse to ensure that the psychosocial and educational needs of the members are met. This position assists members and their families/significant others in making appropriate choices regarding the use of health care services. Care management services may be provided telephonically, in a provider office, or at the members' home.  

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.  

Primary Responsibilities:

• Develop a comprehensive care management plan that will address members' individual needs which include specific objectives, goals, and actions
• Prioritizes member care needs upon initial interaction/assessment and address emerging issues
• Assist members in the management of illness and treatment, monitor adherence, and proactively investigate and address problems that may contribute to non-adherence with the members and other members of the multidisciplinary team
• Assesses reports, data, and other health plan information to identify potential members in need of care management intervention
• Decrease healthcare costs of members by working collaboratively to assist members in managing visits to primary care, to decrease ER Utilization, number of inpatient hospitalizations, readmits to hospital, admissions to skilled nursing facilities and home health
• Monitor the effectiveness of the care management plan and short/long term goals and adjust per member need
• Assesses and prioritizes care referrals to assure program requirements for outreach and engagement are within expected time frames
• Provides member and family education, support, and encouragement, especially to enhance adherence to treatment regimen and follow up care
• Develops communication protocols with physicians in the network, clinic, and community so that early notification and intervention by the care management team occurs for members
• Independently keeps current on areas of care management, quality management, utilization management, member education and preventive health guidelines
• Provides recommendations in the development of policies and procedures that meet the requirements of NCQA, HEDIS, and State and Federal guidelines
• Acts as liaison and members advocate with other care providers and programs
• Participate in team meetings, multi-disciplinary meetings, care conferences and other collaboration via appropriate communication methods (teleconference, video conference, in-person conference)
• Integrates, coordinates and advocates for complex mental and physical health care services from a variety of health care providers and settings, within the framework of planned health outcomes
• Develop an effective support system within the family and community to manage emergency situations and to provide support and safety for the members
• Acts to prevent suicide and homicide in accordance with state licensure requirements
• Supports collection of information and other statistical data relevant to care loads, productivity and health care trends within member population
• Potential for RN oversight of LNP/LVN. Provide clinical supervision and direction to LPN/LVN staff in accordance with state scope of practice and organizational policies
• Maintain overall accountability for member care outcomes delivered by LPN/LVN
• Review and validate care plans developed or supported by LPN/LVN staff
• Provide real-time guidance, coach