NP or PA, Long Term Care - Snohomish, Skagit Counties, WA

Overview

Optum Home & Community Care, 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 Senior Community Care (SCC) product, we work with a team to provide care to patients at home in a nursing home, assisted living for senior housing. May go into some private homes, group homes, and senior apartments. This life-changing work adds a layer of support to improve access to care.

We’re connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

Serving millions of Medicare and Medicaid patients, Optum is the nation’s largest health and wellness business and a vibrant, growing member of the United Health Group family of businesses. You have found the best place to advance your advanced practice nursing career. As an CCM APC you will provide care to your caseload of patients and be responsible for the delivery of medical care services to a pre-designated group of enrollees.

• Deliver cost-effective, quality care to assigned members.
• Manage both medical and behavioral chronic and acute conditions effectively in collaboration with a physician or specialty provider.
• Perform comprehensive assessments and document findings in a concise, comprehensive manner that is compliant with documentation requirements and CMS regulations.
• Provide a comprehensive clinical assessment for Patient Connect members in a short-term stay/transitional setting in collaboration with the case management team to support better care coordination and health outcomes.
• Focus on reducing 30-day hospital readmissions in addition to other primary care responsibilities listed here.
• Ensure all diagnoses are ICD-10 coded accurately and documented appropriately to support the visit's diagnosis.
• Ensure that all quality elements are addressed and documented.
• Conduct initial medication reviews, annual medication reviews and post-hospitalization medication reconciliation.
• Facilitate agreement and implementation of the member’s plan of care by engaging facility staff, families/responsible parties, primary and specialty care physicians.
• Evaluate the effectiveness and efficiency of the plan, making revisions as needed.
• Utilize CCM-established guidelines and protocols.
• Attend and complete all mandatory educational and Learn source training requirements.
• Travel between care sites as required.
• Engage in care coordination across transitions between care settings.
• Continuously monitor member and family needs and adjust the plan of care as conditions change.
• Review orders and interventions for appropriateness and response to treatment to identify the most effective plan of care.
• Evaluate plan of care for cost effectiveness while meeting member/family/provider needs.
• Promote program enhancements and participate in CCM quality initiatives.
• Maintain regular, effective communication with internal and external parties including physicians, members, decision-makers, nursing facilities, CCM staff and other provider groups.
• Actively promote the CCM program in assigned facilities by partnering with key stakeholders to maintain and develop membership growth.
• Demonstrate original thinking and creativity in developing new approaches to concerns/issues.
• Work independently and responsibly with minimal supervision.
• Demonstrate initiative toward individual, team, and organizational goals and objectives.
• Participate in CCM quality initiatives.

• Active and unrestricted license in the state of residence.
• Certified Nurse Practitioner or Physician Assistant through a national board: MSN or DNP, board certified by AANP/ANCC with relevant specialty and preferred certification as ANP, FNP, or GNP; or for PAs, NCCPA certification.
• Current DEA licensure/prescriptive authority or ability to obtain post-hire per state regulations (where allowed).
• Ability to complete physical requirements, including…