Transitional Care Nurse Liaison

UnitedHealth Group•Boulder, CO

1d•$60,200 - $107,400•Remote

About The Position

The Transitional Care Nurse is a registered nurse who provides comprehensive education, coaching and support to high-risk patients during transitions from acute care settings. In partnership with Boulder Community Health, this position focuses on readmission prevention through health education, chronic disease self-management, and connecting patients with appropriate care and community resources. By fostering a patient-centered partnership with the care team, the Transitional Care Nurse enhances the patient experience and collaborates to reduce unnecessary high-cost care for those with complex health needs. The Transitional Care Nurse Liaison fosters relationships with area skilled nursing facilities, inpatient rehab hospitals, and other community partners. Boulder Community Health (BCH) primary care physician clinics are guided by the philosophy of the Patient-Centered Medical Home. The medical home organizes care around patients, while engaging a multidisciplinary care team working proactively to coordinate and track care for each individual patient.

Requirements

Valid and unrestricted RN license (Colorado or compact state license)
2+ years as RN in clinical setting
2+ years of experience with medication reconciliation
2+ years of experience working with an electronic medical record system
Intermediate level of knowledge and the ability to work independently with Microsoft Office suite: Outlook, Word, Excel, and Teams
Ability to work Monday – Friday from 8:00am – 4:30pm, Mountain Time Zone
Reside within a compact state

Nice To Haves

2+ years of experience in chronic disease management, case management, discharge planning, utilization management, or adult acute and chronic care management
Understanding of motivational interviewing techniques or experience with health coaching
Knowledge of patient-centered care and the Patient-Centered Medical Home (PCMH) model
Knowledge of quality metrics and shared savings models
Understanding of Hospital Readmission Reduction Program (HRRP)
Well-developed oral and written communication skills
Ability to employ teach-back methods to assess patient understanding
Reside in the Boulder/Denver area

Responsibilities

Using department methodology, identify patients for transitional care programs
Conduct telephonic outreach to patient, family/caregiver, and/or facility to enroll in transitional care program. Conduct initial assessment and medication reconciliation per workflow
Maintain an active panel of transitional care patients according to department procedures
While patients are enrolled in transitional care, deliver ongoing care according to the treatment plan. Develop and document patient-centered goals and barriers to care
Collaborate as a member of a care team with primary and specialty care providers, medical assistants, care managers, nurses, and other clinic staff to provide care to patients based on best practices
Facilitate communication among care teams to address patient needs and barriers to care
Provide patient education and community referrals for appropriate and timely care. Initiate and revise patient education resources and tools with BCH partner. Update patient records to reflect current condition, treatment plan, and assess/document patient understanding of treatment plan, medications and adherence to medication regimen
Participate in regular and ad hoc team, department, company and BCH partner meetings and committees
Contribute to readmission root cause analyses and quality improvement initiatives
Maintain working knowledge of health laws, protocols, managed care contracts, and insurance and consider financial impacts to patients
Perform effectively in stressful and/or emergency situations
Periodically cross cover for other integrated clinical services staff
Work is generally self-directed and not prescribed
Work with less structured, more complex issues
Identify solutions to non-standard requests and problems
Solve moderately complex problems and/or conduct moderately complex analyses
Work with minimal guidance; seeks guidance on only the most complex tasks
Translate concepts into practice
Provide explanations and information to others on difficult issues
Coach, provide feedback, and guide others
Act as a resource for others with less experience