In-Market Utilization Management RN Clinical Guide
Clinical Operations /
A bit about us:
We’re on a mission to change healthcare — how it’s paid for, delivered, experienced. We want to put people center stage, not process or profit. We are guided by a deep belief that every person on Medicare should be treated like we would treat a member of our own family: with loving care and a profound commitment to their health and well-being.
That’s why we’re gathering a whole bunch of smart, big-hearted people to create a new kind of healthcare company — one that combines compassion, health insurance, clinical care, and technology seamlessly.
We want to throw the long ball with people we love for a cause we believe in. Life is short. Join us.
As a Clinical Guide, you'll have the opportunity to make a difference in the lives of our members. You'll be responsible for providing clinical review of cases using standard criteria to determine the medical appropriateness of inpatient and outpatient services while supporting our members through assessment, care and conservation. You'll serve as an advocate for our members, coordinating care and ensuring they have the necessary resources and support to achieve their health goals (recovering from an illness, improving quality of life, overall well-being, etc.) Our Clinical Guide is committed to integrity and excellence and empowering members to confidently navigate the healthcare system and live healthier lives. Our ideal Clinical Guide is caring, compassionate and solutions-oriented, and is enthusiastic about providing an outstanding experience for Devoted Health’s members.
Responsibilities will include:
- Engage with members and understand their needs, using technology and data to better understand the member and any unspoken needs.
- Performs initial, concurrent, and discharge reviews of all cases, including: using medical guidelines to determine the medical appropriateness of inpatient and outpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating and resolving complex cases or issues as required.
- Reviews current charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients).
- Alerts and collaborates with appropriate leadership concerning patients who do not meet medical appropriateness criteria.
- Obtains admission and continued stay certification or recertification.
- Communicates with attending physician regarding patients who do not meet criteria in order to identify additional documentation needs or potential status change.
- Coordinates care and discharge planning. Makes arrangements for appropriate post-hospital care, including physical and behavioral medicine, transportation, equipment, home health care, etc.
- Identifies documents and communicates potential quality assurance or risk management issues as appropriate.
- Conducts holistic assessment to identify co-morbid conditions, ED/ hospitalization history, medications, psycho-social factors, and member values and preferences.
- Collaborate with our PCP partners.
- Develop care plans in partnership with members and their caregivers - problems, goals, interventions - continuously evaluating the member’s progress.
- Work closely with Local Service Guides to identify community-based organizations to support the member in meeting their goals.
- Collaborate with members, providers, and caregivers to ensure a positive outcome.
- Explain complicated medical terms in plain language.
- Educate members on appropriate care and settings based upon their healthcare needs.
- Support members in understanding diagnostic tests and treatments, including costs, risks, and alternatives so they can make an informed decisions.
- Prepare members for their inpatient and outpatient treatments and coordinate post-treatment care.
- Support and coach members to improve management of their chronic conditions, including medication adherence and compliance
Attributes to success:
- A desire to make a change in the health care experience: you love to serve and make a difference.
- Proven success in building relationships.
- The ability to adjust your tone and approach to different people.
- The ability to articulate and break down complex information.
- Adaptability and comfort in a dynamic, startup environmentTransparency in your work - what’s going well and what’s not
Desired skills and experience:
- Ability to work in a startup, fast paced environment.
- A unrestricted RN license.
- A minimum of 4 years of RN experience.
- A minimum of 3 years experience doing utilization management at a health plan.
- The ability to comfortably multi- task: you’ll be listening, talking and typing all at the same time.
- Team player mentality with a can-do attitude.
- Understanding of CMS guidelines and MA requirements.
Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce. If you lack a specific credential for this position but believe that your strengths and life experiences will propel our mission, we would love to hear from you.
If you love running towards complex challenges and transforming them into solutions, if you want to make a potentially huge impact on many lives, and if you are looking for a disruptive startup with an inspiring and talented team, Devoted Health may be the place for you!
Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.
As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.