Registered Nurse Care at Home Field Case Manager: DC, MD, VA

UnitedHealth Group•Columbia, MD

11h•Onsite

About The Position

For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together. The Optum Care at Home program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of members in their place of residence. The DSNP program combines clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, which includes the clinician, the member’s Primary Care Provider and other providers, and other professionals. This position is open to candidates who live in DC, MD, or VA. This is a field-based position in the greater Washington D.C. area. Expect to spend about 50-75% of your time in the field visiting our members in their homes or in long-term care facilities in the local area. You’ll need to be flexible, adaptable and, above all, patient in all types of situations.

Requirements

Current unrestricted Registered Nurse license in Washington D.C., or the ability to obtain within 90 days of hire date
Certified in Basic Life Support
2+ years of experience working with MS Word, Excel and Outlook
1+ years of experience in post - acute care, such as long-term care
1+ years of clinical case management experience
1+ years of experience with using an Electronic Medical Record
Valid Driver's License and access to reliable transportation
Ability to work in a field-based capacity in Washington, D.C.
Reside within 50 miles of Washington, DC

Nice To Haves

Certified Case Management (CCM)
1+ years of experience working with the geriatric population
1+ years of LTSS (Long Term Services and Supports)
1+ years of HCBS (Home and Community Based Services) experience
Field based experience going into members’ homes
Experience creating care plans
Case Management experience
Background in managing populations with complex medical or behavioral needs

Responsibilities

Assess, plan and implement care management interventions that are individualized for each member and directed toward the most appropriate, least restrictive level of care
Develop and implement care plan interventions throughout the continuum of care as a single point of contact
Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members
Advocate for members and families as needed to ensure the member’s needs and choices are fully represented and supported by the health care team
Identify appropriate interventions and resources to meet gaps (e.g., psychosocial, transportation, long-term care) based on specific consumer needs from both the health care and psychosocial / socioeconomic dimensions of care
Document the plan of care in appropriate EHR systems and enter data per specified
Maintain consumer engagement by establishing rapport, demonstrating empathy, and building a trusting relationship
Collaborate with primary providers or multidisciplinary team to align or integrate goals to plan of care and drive consistent coordination of care
Provide ongoing support for advanced care planning
Reassess plan of care at appropriate intervals based on initial objectives, significant change of condition, or achievement of goals
Understand and operate effectively/efficiently within legal/regulatory requirements
Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standard)
Make outbound calls and receive inbound calls to assess members' current health status
Identify gaps or barriers in treatment plans
Provide member education to assist with self-management
Make referrals to outside sources
Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction
Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels