Case Manager RN or LVN - Inland Empire, CA - Full-time / Part-time

North American Medical Management, California, Inc (NAMM California) partnered with OptumHealth in 2012. NAMM California and OptumHealth share a common goal of bringing patients, physicians, hospitals and payers closer together in the mission to increase the quality, efficiency and affordability of care. NAMM California is a part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system. NAMM California develops and managers provider networks, offering a full range of services to assist physicians and other providers in supporting patient care coordination and their managed care business operations. For over 18 years, NAMM California has been an innovator in health care with a track record for quality, financial stability, extraordinary services and integrated medical management programs. NAMM California is well positioned to continually invest in its infrastructure and systems for the benefit of its provider clients and to accommodate the impending changes that will come forth from healthcare reform.
 
The NAMM California provider clients represent a network of almost 600 primary care physicians and over 3,000 specialists and work with the premier hospitals in their respective markets. 
As a part of our continued growth, we are searching for a Float Case Manager RN or LVN to join our team…
 
Float Nurse Case Manager covers assignments as directed for various IPAs; covers case managers who are on PTO, leave, assigned other temporary duties etc. Most assignments are temporary and are relegated to support multiple IPA staffing needs. Duties are relegated to fill in for Concurrent Review Case Managers at local Acute Hospitals, Skilled Nursing Facilities and Pre-Certification Authorization / referral review Nurse duties.
 
Primary Responsibilities:


Documents Milliman Guideline(s) on every inpatient case within 24 hours of receipt and updates guideline as hospitalization continues for Acute and weekly and as needed for SNF
Notifies patient's Primary Care Physician of admission, discharge and discharge plan within 24 hours of each event as appropriate
Explores care options to reduce cost, decrease length of stay, curtail readmission and influence quality outcomes
Manages cases according to delegation agreement requirements, including notifications regarding LOS >5 days
Meets all health plan contract compliance directives for utilization
Identifies and refers members to Case Management prior to discharge or as deemed appropriate through referral review
Reviews all requests for specialty care, elective surgeries, treatment plans and diagnostic studies in accordance with commercial and senior health plan and CMS timelines
Utilizes health plan, CMS, Milliman and Hayes as sources for documenting appropriateness and standard of care. Seeks consultation from IPA Medical Director when request for services does not meet health plan, CMS, Milliman or Hayes recommendations

Required Qualifications:


High school diploma or GED

Current unrestricted CA Licensed RN or LVN

2+ years clinical experience in acute care (i.e., ICU, CCU, ER, med-surg)

Experience with managed care referral process or case management onsite performing utilization management, discharge planning, or prior authorization

Proficiency in Microsoft Office: Outlook and Word

Travel 50 to 60% to different facilities to provide coverage
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)
 
 
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.
 
Job Keywords: Milliman, MCG, UM, utilization management, RN, MediCal, MediCare, concurrent review, discharge planning, LVN, IPA, Temecula, Ontario, Corona, CA, California