RN Complex Case Manager - Remote On PST - Remote Eligible

Caring. Connecting. Growing Together.

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.

Primary Responsibilities:

1. Conducts clinical evaluation of members per regulated timelines, determining who may qualify for complex case management based on clinical judgment, changes in member's health, social determinants, and gaps in care
2. Creates and implements a case management plan in collaboration with the member, caregiver(s), provider(s), and/or other appropriate healthcare professionals to address the patient's needs and goals
3. Performs ongoing updates of the care plan to evaluate effectiveness, and to document barriers, interventions, and goal achievement
4. Partners with primary providers or multidisciplinary team members to align or integrate goals to plan of care
5. Completes telephonic visits for member engagement and enrollment
6. Uses motivational interviewing to evaluate, educate, support, and motivate change during member contacts
7. Identifies and considers appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed
8. Ensures compliance with quality metrics specific to health plan delegation and accrediting body requirements
9. Conducts self and peer audits on a regular and assigned timeline
10. Maintains caseload per defined medical management department standards
11. Sustains productivity and audit requirements per medical management department standards
12. Demonstrates ability to work independently and implement innovative approaches to complex member situations
13. Determines need for continued member management, creates care plan and facilitates transition to medical management programs
14. Attends departmental meetings and provides constructive recommendations for process improvement
15. 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:

• Associates Degree in Nursing
• Valid multi-state compact license
• Case Management Certification or ability to obtain within 2 years of hire
• 2+ years of job-related experience in a healthcare environment
• Experience utilizing excellent communication, interpersonal, organization and customer service skills
• Knowledge of computer functionality and software applications
• Demonstrated knowledge of relevant state and federal guidelines
• Understanding of relevant health care benefit plans
• Ability to work in Pacific Standard Time

Preferred Qualifications:

• Bachelor's degree or higher in healthcare related field
• 3+ years of experience providing case management and/or utilization review functions within health plan or integrated system
• Proven self-motivated, attention to detail

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). The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.