NP or PA, Senior Community Care - Snohomish, Skagit Counties WA

UnitedHealth Group•Everett, WA

9d•$109,500 - $164,000

About The Position

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We 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 team member of our Senior Community Care (SCC) product, we work with a team to provide care to patients at home in a nursing home, assisted living for senior housing. May go into some private homes, group homes, and senior apartments. This life-changing work adds a layer of support to improve access to care. We’re connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together. Serving millions of Medicare and Medicaid patients, Optum is the nation’s largest health and wellness business and a vibrant, growing member of the UnitedHealth Group family of businesses. You have found the best place to advance your advanced practice nursing career. As an CCM APC you will provide care to your caseload of patients and be responsible for the delivery of medical care services to a pre-designated group of enrollees.

Requirements

Active and unrestricted license in the state which you reside
Certified Nurse Practitioner or Physician Assistant through a national board: Graduate of an accredited master’s degree in Nursing (MSN) program or doctor of nursing practice (DNP) program and board certified through the American Academy of Nurse Practitioners (AANP) or the American Nurses Credentialing Center (ANCC), Adult-Gerontology Acute Care Nurse Practitioners (AG AC NP), Adult/Family or Gerontology Nurse Practitioners (ACNP), with preferred certification as ANP, FNP, or GNP
For PAs - Certified Physician Assistant through a national board: Graduate of an accredited Physician Assistant degree program and currently board certified by the National Commission on Certification of Physician Assistants (NCCPA)
Current active DEA licensure/prescriptive authority or ability to obtain post-hire, per state regulations (unless prohibited in state of practice)
Ability to complete physical requirements of the job including moving a 30-pound bag in and out of the car, navigating stairs and a variety of dwelling conditions, remain in a stationary position and position self to perform physical assessment
Access to reliable transportation that will enable you to travel to client and / or patient sites within a designated area
Ability to gain a collaborative practice agreement, if applicable in your state

Nice To Haves

1+ years of hands-on post grad experience within long-term care, short-stay transitional setting care, and/or assisted living
Understanding of Geriatrics and Chronic Illness
Understanding of Advanced Illness and end of life discussions
Proficient computer skills including the ability to document medical information with written and electronic medical records
Ability to develop and maintain positive customer relationships
Adaptability to change

Responsibilities

Deliver cost-effective, quality care to assigned members.
Manage both medical and behavioral chronic and acute conditions effectively in collaboration with a physician or specialty provider.
Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations
Providing a comprehensive clinical assessment for the Patient Connect members in a short term stay/transitional setting in collaboration with the case management team to support better care coordination and health outcomes
With a focus on reduction in 30-day hospital readmissions in addition to other primary care responsibilities listed here.
Responsible for ensuring that all diagnoses are ICD10, coded accurately, and documented appropriately to support the diagnosis at that visit.
The APC is responsible for ensuring that all quality elements are addressed and documented.
The APC will do an initial medication review, annual medication review and a post-hospitalization medication reconciliation.
Facilitate agreement and implementation of the member’s plan of care by engaging the facility staff, families/responsible parties, primary and specialty care physicians.
Evaluate the effectiveness, necessity and efficiency of the plan, making revisions as needed.
Utilizes practice guidelines and protocols established by CCM.
Must attend and complete all mandatory educational and Learnsource training requirements.
Travel between care sites mandatory
Understand the Payer/Plan benefits, CCM associate policies, procedures and articulate them effectively to providers, members and key decision-makers.
Assess the medical necessity/effectiveness of ancillary services to determine the appropriate initiation of benefit events and communicate the process to providers and appropriate team members.
Coordinate care as members transition through different levels of care and care settings.
Continually monitor the needs of members and families while facilitating any adjustments to the plan of care as situations and conditions change.
Review orders and interventions for appropriateness and response to treatment to identify most effective plan of care that aligns with the member’s needs and wishes.
Evaluate plan of care for cost effectiveness while meeting the needs of members, families and providers to decreases high costs, poor outcomes and unnecessary hospitalizations
Regular and effective communication with internal and external parties including physicians, members, key decision-makers, nursing facilities, CCM staff and other provider groups.
Actively promote the CCM program in assigned facilities by partnering with key stakeholders (i.e.: internal sales function, provider relations, facility leader) to maintain and develop membership growth.
Exhibit original thinking and creativity in the development of new and improved methods and approaches to concerns/issues.
Function independently and responsibly with minimal need for supervision.
Demonstrate initiative in achieving individual, team, and organizational goals and objectives.
Participate in CCM quality initiatives