Care Coordinator, Onsite - Ennis, TX; Hybrid - RN​/PT​/OT​/ST

Overview

Optum Home & Community Care Delivery, part of the United Health 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 Home and Community Care Delivery product, we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days  are connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

The Care Coordinator - Onsite plays an integral role in optimizing patients  recovery journeys. The Care Coordinator - Onsite completes weekly functional assessments and engages the post-acute care (PAC) inter-disciplinary care team to coordinate discharge planning to support the member s PAC journey. The position engages patients and families to share information and facilitate informed decisions. By serving as the link between patients and the appropriate health care personnel, the Clinical Review Coordinator
- Onsite is responsible for ensuring efficient, smooth, and prompt transitions of care.

• Serve as the link between patients and the appropriate health care personnel to ensure efficient, smooth, and prompt transitions of care
• Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and CMS criteria upon admission to SNF and periodically through the patient stays
• Review target outcomes and discharge plans with providers and families
• Complete all SNF concurrent reviews, updating authorizations in a timely manner
• Collaborate effectively with the patients  health care teams to establish an optimal discharge. The health care team includes physicians, referral coordinators, discharge planners, social workers, physical therapists, etc.
• Assure patients  progress toward discharge goals and assist in resolving barriers
• Participate weekly in SNF rounds, providing accurate and up-to-date information to the Home & Community Care Delivery Sr. Manager or Medical Director
• Assure appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services
• Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed
• Attend patient/family care conferences
• Assess and monitor patients  continued appropriateness for SNF setting (as indicated) according to CMS criteria
• When Home & Community Care Delivery is delegated for utilization management, review referral requests that cannot be approved for continued stay and forward to licensed physicians for review and issuance of the NOMNC when appropriate
• Coordinate peer-to-peer reviews with Home & Community Care Delivery Medical Directors
• Support new delegated contract start-up to ensure experienced staff work with new contracts
• Manage assigned caseload efficiently and effectively using time management skills
• Enter timely and accurate documentation into the coordinate system
• Daily review of census and identification of barriers to managing independent workload and ability to assist others
• Review monthly dashboards, readmission reports, quarterly and other reports with the assigned Clinical Team Manager, as needed, to assist with opportunities for improvement
• Adhere to organizational and departmental policies and procedures
• Maintain confidentiality of all PHI information in compliance with HIPAA, federal and state regulations, and laws
• Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business
• Keep current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies, and benefits)
• Adhere to all local, state, and federal regulatory policies and procedures
• Promote a positive attitude and work environment
• Attend Home & Community Care Delivery meetings as requested
• Maintain patient information confidentiality as required by applicable laws and procedures
• Perform other duties and responsibilities as required, assigned, or requested

• Active, unrestricted registered clinical license required in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist
• 5+ years of clinical experience
• Ability to support specific location(s) for on-site facility needs within 30-miles maximum radius of home location based on manager discretion
• Reside within or near the county listed on the job description
• Driver s License and access to reliable transportation

• Experience working with the geriatric population
• Familiarity with care management, utilization/resource management processes and disease management programs
• Patient education background,…