Social Worker Care at Home Field Care Coordinator: DC, MD, VA

UnitedHealth Group•Washington, DC

3h•Onsite

About The Position

Optum Home & Community Care, part of the Optum family of businesses, is building an integrated care model to holistically address an individual’s physical, mental and social needs, helping patients access and navigate care anytime and anywhere. As a team member of the Optum Care at Home team, you will work in an interdisciplinary care environment to help patients navigate the health care system and connect them to key support services, aiming to keep patients well at home through preventive care. The Optum Care at Home program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care for 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 is a field-based position in the greater Washington D.C. area, requiring an expectation to spend about 50-75% of your time in the field visiting members in their homes or in long-term care facilities in the local area. The role requires flexibility, adaptability, and patience in all types of situations.

Requirements

Master’s degree in social work or another related clinical field
Active and unrestricted LICSW or LGSW license in Washington D.C. or ability to obtain Washington, D.C. License within 90 days of hire
2+ years of experience in long-term care, home health, hospice, public health or assisted living
2+ years of experience working with MS Word, Excel and Outlook
1+ years of experience with using an Electronic Medical Record
1+ years of clinical case management experience
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, D.C

Nice To Haves

Certified Case Management (CCM)
1+ years of experience working with geriatric population
1+ years of LTSS (Long Term Services and Supports)
Experience with arranging community resources
Field-based work experience going into member homes
HCBS (Home and Community Based Services) 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, and connections to resources such as Home Health Aides or Meals on Wheels