Description

Optum NY/NJ, is seeking a Senior RN Case Manager to join our team in Fishkill, NY. 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. 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.

Function is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring, and evaluating). This includes case management, coordination of care, and medical management consulting, health education, coaching and treatment decision support. Coordinates, supervises and is accountable for the daily activities of business support, technical or production team or unit. The impact of work is most often at the local level.

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Position Highlights & Primary Responsibilities:

• Maintain caseload
• Reviews the work of others
• Develops innovative approaches
• Coordinates work activities with supervisors and/or managers
• Serve as a clinical resource and coach for Complex Case, Disease and Transitional Case
• Management programs, and ED Follow-up
• Act as primary preceptor for RN and LPN Case Managers
• Assign and support preceptor for all other roles
• Support and maintenance of relationships with affordability and vendor programs, including and not limited to palliative care, continuum/fee for services programs, and patient care conferences
• Anticipates customer needs and proactively develops solutions to meet them.
• Serves as a key resource on complex and/or critical issues
• Solves complex problems and develops innovative solutions
• Performs complex conceptual analyses
• Reviews work performed by others and provides recommendations for improvement.
• Forecasts and plans resource requirements
• Authorizes deviations from standards
• May lead functional or segment teams or projects
• Provides explanations and information to others on the most complex issues
• Motivates and inspires other team members
• Conduct call monitoring and case auditing of staff and implementing performance improvement plans
• Ability to work in a fast-paced environment
• Facilitate the complaint process by engaging member, family, and caregivers telephonically
• Establish a process for member education to assist with self-management goals, disease management or acute condition
• Utilize evidenced-based practice to develop interventions
• Establish a process to utilize motivational interviewing techniques to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy
• Manage the quality of clinical assessments and Care Plans
• Coordinate regular clinical reviews of high-risk cases with members of the Interdisciplinary Care Team (IDCT)
• Ensure adherence to relevant state and federal guidelines (e.g., Medicare, Medicaid, SNP, Commercial) and regulatory bodies (e.g., CMS, NCQA, URAC, InterQual) for Complex Case, Disease and Transitional case management
• Demonstrate understanding of utilization management processes
• Maintain in-depth knowledge of all company products and services as well as customer issues and needs through ongoing training and self-directed research
• Monitor staff caseload in an efficient and effective manner to ensure optimal productivity
• Monitor and ensure timely and accurate documentation in the care management electronic software system to comply with documentation requirements and achieve individual and collective audit scores of 95% or better monthly
• Attends meetings and participates on committees as requested
• Identifies opportunities for process improvement in all aspects of member care
• Supports data collection and closing of care gaps and quality metrics as assigned and assists the healthcare team in meeting quality metrics
• Must always maintain strict confidentiality
• Must adhere to all department/organizational policies and procedures
• Performs all other related duties as assigned

Optum NY/NJ was formed in 2022 by bringing together Riverside Medical Group, CareMount Medical and ProHealth Care. The regional alignment combines resources and services across the care continuum - from preventative medicine to diagnostics to treatment and beyond across New York, New Jersey, and Southern Connecticut. As a Patient Centered Medical Home, Optum NY/NJ can provide patient-focused medical care to the entire family. You will find our team working in local clinics, surgery centers and urgent care centers, within care models focused on managing risk, higher quality outcomes and driving change through collaboration and innovation. Together, we're making health care work better for everyone.

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:

• Current, unrestricted RN license in both New York and New Jersey
• Bachelor of Science in Nursing (BSN)
• Associate of Science in Nursing
• 5+ years of diverse clinical experience; preferred in managed care (delegated medical management), Complex Case Management, Disease Management and Transitional Case Management
• 2+ years of diverse clinical experience, preferably in managed care (delegated medical management), Complex Case Management, Disease Management and Transitional Case Management
• Proven expert knowledge of case management principles, as evidenced by certification in Case Management (CCM) or willing to obtain within 12 months of employment
• Proven knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, SNP, Commercial) and regulatory bodies (e.g., CMS, NCQA, URAC, InterQual)
• People-management experience, to include motivational leadership, ability to implement performance improvement plans, and a drive to see employees succeed in their work
• Experience managing direct reports to performance metrics
• Proficient with Microsoft Office applications including Word, Excel, and PowerPoint, and Adobe products
• Remote work experience

Preferred Qualifications:

• 5+ years of managed care (delegated medical management), Complex Case Management,
• 1+ years of recent leadership experience (manager, supervisor, team lead, etc.), with ability to partner with staff to build high-performing teams
• Disease Management and Transitional Case Management experience
• Knowledge of utilization management, quality improvement, and discharge planning
• Ability to cultivate a solid internal culture designed around collaboration, feedback, motivation, and accountability
• Solid communication and interpersonal skills
• Demonstrated ability to work in a fast pace, multi-tasking team environment while meeting deadlines
• Highly skilled in leading change efforts and in building solid partnerships with business-line executives
• Ability to summarize complex issues and problems into a concise report focused on key findings and outcomes
• Ability to consistently manage up and down
• Ability to complete initiatives with minimal supervision
• Proficiency in developing communication strategies for a wide array of audiences that support strategic objectives
• Demonstrated sophisticated written and verbal presentation abilities; experience with the development of presentation materials (collateral, proposals, presentations, talking points, etc.)
• Proven proficiency in the management of time, flexibility, and influencing colleagues to meet demanding project/requested timelines

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 to $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.