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The Clinic Case Manager is responsible for fostering collaboration and a team approach for successfully supporting patients with high-risk health conditions to navigate the healthcare system. Promotes empowerment by facilitating the role of an educator, resource, and advocate for patients and their families to ensure a maximum quality of life. Interacts and collaborates with multidisciplinary care teams, to include physicians, nurses, pharmacists, case managers, social workers, and other educators. Acts as a clinic resource for the value-based population. Works in a less structured, self-directed environment and performs all delegated nursing duties within the scope of a RN license of the applicable state board of nursing.

Position in this function ensures compliance to contractual and service standards as identified by relevant health insurance plans. Adheres to policies, procedures, and regulations to ensure compliance and patient safety. Participation in Compliance and required training is a condition of employment.

Primary Responsibilities:

• Role embedded within the primary care clinic, working directly with patients, clinical and non-clinical teams
• Participates in the identification of a focused clinic patient panel, as defined by the manager of Medical Management
• Supports longitudinal care of the patient with chronic care conditions:
  • Communicates with patients, responding to patient questions via patient portal and other modalities
  • Performs assessment of health conditions and implements care plan in collaboration with the member, caregiver(s), clinician(s), and/or other appropriate healthcare professionals to address need and goals
  • Pursues appropriate interventions to reduce risk of condition exacerbation, ER and hospitalization utilization
  • Performs medication reconciliation and collaborates with clinician partner as needed
  • Conducts Motivational Interviewing and Self-Management Goal setting
  • Provides patient education
  • Creates referrals to appropriate agencies and resources
• Supports transition of care from Emergency Department or inpatient stay to outpatient setting:
  • Performs assessment of transitional needs
  • Performs medication reconciliation
  • Establishes and reviews contingency plan
  • Provides patient education
  • Assists with post discharge needs such as home health care, prescriptions, transportation, Durable Medical Equipment (DME), appointments
• Coordinates with providers to establish or update individualized plan of care
• Creates referrals to appropriate internal and external resources
• Achieves Quality Measures outcomes via reduction in HEDIS Gaps in Care
• Performs accurate and timely documentation in the electronic medical record
• Performs triage and clinical tasks within their scope of practice
• Participates in daily huddles and monthly clinic meetings, as required
• Prepares accurate and timely reports, as required
• Maintains continued competence in nursing practice and knowledge of current evidence-based practices
• Performs ongoing updates of the care plan to evaluate effectiveness, and to document interventions and goal achievement
• Maintains a working knowledge of community resources
• Serves as facilitator and resource for other members of the Medical Group clinical team
• Attends departmental meetings and provides constructive recommendations for process improvement
• Performs other 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:

• Associate degree in nursing 
• Valid NM RN license or valid multi-state compact license
• Current BLS certification
• 3 years of job-related experience in a healthcare environment
• Knowledge of medical terminology
• Proven skilled with MS Office software applications

Preferred Qualifications:

• Bachelor’s degree or higher in healthcare related field 
• 2 years of experience providing prior authorization or case management within health plan or integrated system
• Proven excellent communication, interpersonal, organization and customer service skills
• Proven self-motivated, solid computer skills
• Proven attention to detail
• Proven ability to multi-task and work under pressure

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

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.