Care Coordinator, Onsite--Sugarland, TX (Hybrid--RNPT/OT/ST)

UnitedHealth Group•Sugar Land, TX

9h•Hybrid

About The Position

Optum Home & Community Care Delivery is building an integrated care model to holistically address individuals' physical, mental, and social needs, helping patients access and navigate care anytime and anywhere. As part of Care Transitions, the team delivers compassionate care to seniors nationwide, innovating healthcare from hospital to home. The Onsite Care Coordinator is crucial in optimizing patients' recovery journeys by completing weekly functional assessments and engaging the post-acute care (PAC) inter-disciplinary care team to coordinate discharge planning. This role involves engaging patients and families to share information and facilitate informed decisions, serving as the link between patients and appropriate healthcare personnel to ensure 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
Must reside within or near the county listed in the job description.
5+ years of clinical experience
Ability to mobilize to and within sites within an assigned local or regional market/area, including car transport, up to 85% of the time

Nice To Haves

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

Responsibilities

Ensure efficient, smooth, and prompt transitions of care by serving as the link between patients and appropriate health care personnel.
Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed, collaborating effectively on discharge goals and assisting 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.