Field Transition Care Coordination
About The Position
The Field Transition Care Coordinator applies clinical knowledge to coordinate transitions for assigned members, primarily those who are medically complex and need intensive medical and psychosocial support. Transitions may be from nursing facilities to the community or between community-based settings. The role works directly with members to support appropriate access to services and providers, identify health risks early, provide education and prevention, and coordinate care across the continuum using the six essential activities of case management as defined by CMSA. It supports appropriate, cost-effective services as members transition between residential settings and collaborates with Care Coordination, Case Management, Utilization Review, and Behavioral Health team members. This is a field-based role for candidates who reside in or within commutable driving distance of Wilson, Smith, and Davidson Counties. The role may be performed remotely, with travel to meet members and providers. The coordinator conducts telephonic and face-to-face assessments, develops and monitors individualized care plans, coordinates referrals and services, documents work in Health Plan systems, and supports safe transitions and regulatory compliance.
Requirements
- Current Nursing License (RN) or LBSW License.
- At least 2 years of clinical experience as an RN or LBSW.
- At least 1 year of experience with MS Office, including Word, Excel, and Outlook.
- Excellent organization, communication, and time management skills.
- Reside in or within commutable driving distance of Wilson, Smith, and Davidson Counties.
- Access to reliable transportation and a valid U.S. driver's license, with ability to travel up to 50% within an assigned territory to meet with members and providers.
- Adhere to UnitedHealth Group's Telecommuter Policy if telecommuting.
- Pass a drug test before beginning employment.
Nice To Haves
- BSN, master's degree in a clinical field, or master's degree in Social Work (MSW).
- CCM certification.
- At least 1 year of community case management experience coordinating care for individuals with complex needs.
- Long-term care experience.
- Experience working in team-based care.
- Working knowledge of Medicare and Medicaid regulations.
- Working knowledge of medical terminology.
Responsibilities
- Apply clinical knowledge to support efficient case management for members accessing Medicare and Medicaid benefits.
- Incorporate evidence-based clinical practices into care coordination activities.
- Deliver member-centered, individualized self-management support and patient education.
- Ensure appropriate utilization and consistent application of health benefits and services.
- Conduct telephonic and face-to-face assessments according to Health Plan policy and procedure, including system documentation and state-prescribed timeframes.
- Serve as a member advocate and facilitator to resolve issues that may be barriers to care.
- Educate members and providers and coordinate community resource referrals.
- Develop and implement individualized, member-centered care plans based on identified needs and proactive collaboration with members, families, and providers.
- Collaborate and communicate with Care Coordination Team members to improve care delivery quality and efficiency and support smooth transitions of coordination activities.
- Monitor hospital encounters of assigned members and evaluate continued safety for transitions between residential settings.
- Refer clinical decisions outside the role's authority or involving members who do not meet established criteria to a manager for review and decision.
- Participate in Health Plan Quality Improvement, recognize quality-of-care issues, and forward information for review and resolution.
- Use Health Plan software to enter service requests and document and monitor member care coordination and service delivery.
- Maintain time-sensitive documentation to support regulatory compliance.
- Coordinate services for members in accordance with Health Plan policy.
- Perform other duties as assigned.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase program.
- 401(k) contribution, subject to eligibility requirements.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
