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UM Case Manager - Private Duty Nurse - Telecommute - Springfield, MO

UnitedHealth Group

Springfield, MO
Job Code:
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Job Details

UM Case Manager - Private Duty Nurse - Telecommute - Springfield, MO(Job Number:708000)

Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. Bring your skills and talents to a role where you'll have the opportunity to make an impact on a huge scale. This is the place to do your life's best work.(sm)


***This is a telecommuter position with 25 - 50% travel in the Springfield area.  It does require that the individual is licensed in the state of Missouri and lives close to Springfield, MO.***

Primary Responsibility:

  • Conduct thorough and objective initial and ongoing face - to - face assessments of the member within specific mandated intervals to determine current status and needs, including physical, behavioral, functional, psychosocial and financial and health status expectation
  • Conduct telephonic, face - to - face and other additional assessments as needed to address member change in condition
  • Perform utilization management, utilization review, or concurrent review (on-site or telephonic inpatient care management)
  • Determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
  • Conduct telephonic or on - site grand rounds on members experiencing changes in condition
  • Identify members with the potential for high - risk complications and coordinate the appropriate supported self - care in conjunction with the member and care coordination team
  • Act as an advocate for an individual's care needs by identifying and communicating opportunities for care interventions, including identifying and addressing functional deficits and gaps in care
  • Develops member specific Plan of Care that will be utilized to obtain authorizations for  appropriate home and community based services, collaborating with staff to obtain authorization for those services and confirms that services are being provided and the member's needs are being met while transitioning from nursing facility to home
  • Management of critical transitions, supporting legacy discharge planning staff with member transition to the home setting
  • For members transitioning to a setting other than a community - based residential alternative setting, monitor the initiation and daily provision of services in accordance with the member's plan of care and take the immediate action to resolve gaps in care
  • Develop and implement targeted strategies to improve health, functional or quality of life outcomes, such as disease management or pharmacy management
  • Serve as a point of contact for coordination of all physical health, behavioral health and other home and community based services
  • Proactively educate members about the program
  • Monitor hospitalizations and institutional facility admissions and re - admissions to identify issues and implement strategies to improve outcomes
  • Provide assistance in resolving concerns about service delivery or providers
  • Coordinate with member's primary care provider, specialists and other providers and care programs to ensure comprehensive, holistic, person - centered approach to care;
  • Compare member's plan of care to establish pathways to determine variances and then intervene as indicated
  • Routinely assess and monitor member's status, needs and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments to their plan of care, providers and / or services to promote better outcomes
  • Report quantifiable impact, quality of care and/or quality of life improvements as measured against the care coordination goals
  • Establish and maintain professional working relations with referral sources, community resources and care providers
  • Collaborates with the peers on member admissions, transitioning and/or discharge planning

Job Case Management
Primary Location US-MO-Springfield
Other Location 
Organization C&S Exec HP Operations
Schedule Full-time
Number of Openings 1
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UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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