Optum Home & Community Care, part of the UnitedHealth 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 Optum Home & Community Care 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 at home.

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

The Cross-Market Care Coordinator works in a dual role as a Skilled Inpatient Care Coordinator (SICC) and Transitional Care Coordinator (TCC). The Cross-Market Care Coordinator plays an integral role in the patient's journey towards better well-being by serving as the communication link between the patient and their interdisciplinary health care team in both the acute care and post-acute care (PAC) settings.

The Care Coordinator is responsible for identifying the appropriate first PAC setting in acute and utilizing Predict to align expectations and discharge planning efforts in PAC. In both settings, the Care Coordinator evaluates a defined population for transitional needs post-discharge to improve outcomes. The Care Coordinator engages hospital care teams, physicians, post-acute care providers, and patients and their families/caregivers while providing objective information and support throughout the care continuum focusing on safe transitions of care and improving the patient journey. A successful Cross-Market Care Coordinator demonstrates a high degree of adaptability and flexibility and is one whose skills and proficiency allow for quick integration - in part or in whole - into an existing market or client model.

If you are located in Albany, NY, you will have the flexibility to work remotely* as you take on some tough challenges. If not in Albany, then have an active New York license or compact license in an EST time zone area to support the business needs.

Primary Responsibilities:

• Perform SICC and/or TCC responsibilities telephonically as directed by leadership
• Engage and collaborate with in-market leaders as needed based on current assignment or as directed by leadership. This could include in-market Clinical Team Managers or Provider Relations Managers
• Participate in the collaborative patient care process to assess, plan, implement, coordinate, monitor, and evaluate options and services required to meet patients' post-acute health needs, using communication and available resources to promote quality, cost-effective outcomes
• Maintain Coordinate case documentation per established standards
• Provide telephonic post-discharge support to assist a defined population of patients in meeting short-term needs to prevent readmissions. This may include:
• Collaboration with other care team members such as home health providers to avoid redundant telephonic follow up and coordinate care
• Address end of life issues including hospice and palliative care options
• Practice cultural competency with awareness and respect for diversity
• Facilitate the development of culturally sensitive individualized transitional care plans for services that including clinical, psycho-social, and environmental needs. Monitor and evaluate the effectiveness of plans and make recommendations for changes in the transitional care plan that incorporates transitional needs, as indicated
• Provide individualized evidence-based condition-specific patient education directed at self-care and reduction of exacerbations. Education is delivered at the appropriate health literacy level in a culturally sensitive manner
• Perform all Transitional Care Coordinator (TCC) and/or Skilled Inpatient Care Coordinator (SICC) specific functions as assigned:
• Assist in identifying patients who qualify for the BPCI-A program
• May perform functional assessments on a defined population of patients using clinical skills and proprietary PAC management workflow system and functionally based assessment technology tools. Provide outcome targets to the appropriate audience
• Utilize proprietary technology and industry-standard evidence-based tools, such as Predict™ and InterQual, for consideration of the appropriate level of care, readmission risk, and needed interventions
• Collaborate effectively with patients' interdisciplinary health care teams to coordinate the target length of stay and an optimal transition plan to the most appropriate PAC setting and connecting patients to community resources and additional services as appropriate. The health care team includes physicians, health plan UM/CM Nurse, hospital discharge planners, referral coordinators, etc.
• Communicate with hospital case management and physicians on identified patients that do not meet criteria and assist with developing appropriate discharge setting as needed
• Participate in weekly readmission and other type rounds as needed based upon opportunities
• Attend weekly SNF Rounds and other meetings
• Participate in SNF IDT (Interdisciplinary Teams Rounds) weekly providing accurate and up to date information to the Management team
• Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed including attending patient/family care conferences
• Manage assigned caseload in an efficient and effective manner utilizing good time management skills
• Keep current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies, and benefits)
• Pursue and maintain multi-state licensure to meet business needs
• Initiate and maintain access to multiple Electronic Medical Record (EMR) platforms
• Adhere to organizational departmental policies and procedures
• Adhere to all local, state, and federal regulatory policies and procedures
• Promote a positive attitude and work environment
• Attend 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

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Active, unrestricted registered clinical license - Registered Nurse, Physical Therapist, Occupational Therapist or Speech Therapist
• 3+ years of clinical experience
• Proficient with Microsoft Office applications including Word, Excel, and Outlook
• Willingness to obtain additional licenses

Preferred Qualifications:

• 2+ years of case management experience
• Patient education background, rehabilitation, and/or home health nursing experience
• Experience working with geriatric population
• Experience in a Skilled Nursing Facility
• Demonstrated detail-oriented
• Demonstrated team player
• Proven solid problem solving, conflict resolution, and negotiating skills
• Demonstrated exceptional verbal and written interpersonal and communication skills
• Proven independent problem identification/resolution and decision-making skills
• Demonstrated ability to prioritize, plan, and handle multiple tasks/demands simultaneously

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy.

New York Residents Only: The hourly range for this role is $33.75 to $66.25 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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