RN Field Case Manager, Care at Home - King, Pierce & Snohomish Counties, WA

UnitedHealth Group•Lakewood, WA

12d•$91,500 - $137,000

About The Position

The RN Field Case Manager works in Optum’s Care at Home Dual Special Needs Plan program, a longitudinal, integrated care delivery program that coordinates clinical care for patients in their homes. The program uses trained clinicians and an interdisciplinary care team to provide individualized interventions, annual evaluations, longitudinal visits for higher-risk beneficiaries, care coordination during transitions from hospitals or nursing homes, and ongoing care management. The RN works primarily in patients’ homes as part of a care team that includes a Nurse Practitioner, Behavioral Health Advocate, Care Navigator, and other supporting team members. Care is delivered through in-home visits, telephone outreach and consultations, and interdisciplinary team activities. The RN provides care, develops and updates care plans, and educates and counsels patients to promote and maintain health. The role includes managing medical, behavioral, and social determinants of health needs in accordance with applicable state and federal rules and nursing standards of care, in collaboration with other care team members.

Requirements

Active, unrestricted RN licensure in the state of residence and state of assignment.
At least 2 years of relevant experience.
Experience assessing the medical needs of patients with complex behavioral, social, and/or functional needs.
Ability to work with diverse care teams in varied settings, including non-clinical settings such as patient homes.
Solid computer skills, including experience using electronic medical records.
Ability to travel up to 75% of the time for field-based work.
Valid driver’s license and access to reliable transportation.
Ability to physically navigate home settings and lift 30 pounds.
Reliable transportation for commuting to member homes.

Nice To Haves

Certified Case Management (CCM) certification.
Experience in a home health care or hospice setting.
Effective time management and communication skills.

Responsibilities

Assess patients’ health status within the scope of licensure and at the frequency established in the model of care.
Establish goals to meet identified health care needs.
Plan, implement, and evaluate responses to the plan of care.
Collaborate with the interdisciplinary team to engage resources and strategies addressing medical, functional, and social barriers to care.
Work with mental health clinicians to bridge gaps between mental and physical health.
Review the Daily On Call Report to monitor assigned patients calling Urgent Care and schedule them with an APC or RN as clinically indicated.
Consult with patients’ PCPs, specialists, and other health care professionals as appropriate.
Assess patients’ needs for community resources and make appropriate referrals.
Facilitate patient transitions within and between health care settings in collaboration with the primary care physician and other treating physicians.
Complete and accurately document information in patients’ electronic medical records.
Counsel and educate patients and family members on health maintenance, disease prevention, condition trajectory, and follow-up needs as appropriate during visits.
Verify and document patient and/or family understanding of the condition, plan of care, and follow-up recommendations.
Participate actively in organizational quality initiatives.
Participate in collaborative interdisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery.
Initiate internal and external referrals as clinically indicated.
Maintain credentials essential for practice, including licensure, applicable certification, and continuing education units.
Demonstrate commitment to UnitedHealthcare’s mission, core values, and goals, integrating compassion, integrity, performance, innovation, and relationships into patient care.