Care Coordinator, Onsite - Conroe, TX (Hybrid - RN/PT/OT/ST)

UnitedHealth Group•Conroe, TX

9h•Hybrid

About The Position

Optum Home & Community Care Delivery, part of the Optum family of businesses, is creating something new in health care. They are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual’s physical, mental and social needs – helping patients access and navigate care anytime and anywhere. As a member of Care Transitions, they combine the talents of their dedicated staff and leading-edge technology to deliver compassionate care to seniors nationwide. With millions of lives touched, they are innovating the way health care is provided from hospital to home so seniors can lead more fulfilling lives. A career with them means making an impact in the lives of those they serve, including vulnerable populations who benefit from care that is more efficient, more effective and more human. Their environment empowers team members to elevate interactions with each other and the experiences delivered to patients, giving them more days at home. The Onsite Care Coordinator plays an integral role in optimizing patients’ recovery journeys. The Care Coordinator completes weekly functional assessments and engages the post-acute care (PAC) inter-disciplinary care team to coordinate discharge planning to support the members PAC journey. The position engages patients and families to share information and facilitate informed decisions. By serving as the link between patients and the appropriate health care personnel, the Care Coordinator is responsible for ensuring efficient, smooth, and prompt transitions of care.

Requirements

Active, unrestricted registered clinical license required in state of hire – Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist
Candidate hired will support specific location(s) for on-site facility needs within 30-mile maximum radius of home location based on manager discretion
5+ years of clinical experience
Reside within or near the county listed in the job description.
Ability to mobilize to and within sites within an assigned local or regional market/area, including car transport, up to 85%25 of the time
Driver’s License and access to a reliable transportation

Nice To Haves

Patient education background, rehabilitation, and/or home health nursing experience
Experience working with the geriatric population
Familiarity with care management, utilization/resource management processes and disease management programs
Proficient with Microsoft Office applications including Outlook, Excel and PowerPoint

Responsibilities

By serving as the link between patients and the appropriate health care personnel, the Care Coordinator is responsible for ensuring efficient, smooth, and prompt transitions of care
Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed. Collaborate effectively on discharge goals and assist in resolving barriers
Collaborate effectively with members health care teams with individualized communication and participation in interdisciplinary team meetings
Review target outcomes and discharge plans with providers and families
Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays
Assess and monitor patients’ continued appropriateness for SNF setting (as indicated) according to CMS criteria
Complete all SNF continued stay reviews, updating authorizations on a timely basis
When Care Transitions is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forwarded to licensed physicians for review and issuance of the NOMNC when appropriate
Perform other duties and responsibilities as required, assigned, or requested