Care Coordinator, Onsite - Atlanta, GA-(Hybrid-RN, PT, OT,ST

Join to apply for the Care Coordinator, Onsite - Gainesville GA--(Hybrid-RN, PT, OT, ST) role at Optum
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For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care. Join us to start Caring. Connecting. Growing together.

The Care Coordinator‑Onsite plays an integral role in optimizing patients' recovery journeys. The position follows a hybrid schedule with three in‑office days per week.

• Serve as the link between patients and appropriate health‑care personnel, ensuring 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 throughout the patient stay.
• Review target outcomes and discharge plans with providers and families.
• Complete all SNF concurrent reviews, updating authorizations in a timely manner.
• Collaborate with the patient’s health‑care team—including physicians, referral coordinators, discharge planners, social workers, physical therapists, and others—to establish an optimal discharge plan.
• 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 H&C Transitions Sr. Manager or Medical Director.
• Ensure 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 according to CMS criteria.
• When H&C Transitions is delegated for utilization management, review referral requests that cannot be approved for continued stay and forward them to licensed physicians for review and issuance of the NOMNC when appropriate.
• Coordinate peer‑to‑peer reviews with H&C Transitions Medical Directors.
• Support new delegated contract start‑up to ensure experienced staff work with new contracts.
• Manage assigned caseload efficiently, utilizing time‑management skills.
• Enter timely and accurate documentation into the system.
• Daily review of census and identification of barriers to managing independent workload and assisting others.
• Review monthly dashboards, readmission reports, quarterly reports, and other reports with the assigned Clinical Team Manager, as needed, to identify opportunities for improvement.
• Adhere to organizational and departmental policies and procedures.
• Maintain confidentiality of all PHI 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.
• Promote a positive attitude and work environment.
• Attend H&C Transitions meetings as requested.
• Hold patients’ protected health information confidential as required by applicable laws, regulations, or agency/institution procedures.
• Perform other duties and responsibilities as required, assigned, or requested.

• Active, unrestricted registered clinical license in the 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 a 30‑mile 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, rehabilitation, and/or home‑health nursing experience.
• Proficient with Microsoft Office applications including Outlook, Excel, and PowerPoint.
• Proven detail‑oriented.
• Proven ability to prioritize, plan, and handle multiple…