Care Coordinator, Remote, Wyoming (Remote/ RN/PT/OT/ST)

About the position 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 naviHealth 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 Care Coordinator, Remote functions as a telephonic/remote Care Coordinator. The Care Coordinator plays an integral role in the patient's recovery journey. The Care Coordinator completes weekly functional assessments and engages the post-acute care (PAC) inter-disciplinary care team to coordinate discharge planning to support the members 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 Care Coordinator is responsible for ensuring efficient, smooth, and prompt transitions of care. A successful Care Coordinator, Remote 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. Responsibilities • 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 utilizing 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 on a timely basis. • Collaborate effectively with the patients' health care teams to establish an optimal discharge. • 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. • Assure appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services. • Engage with patients, families, or caregivers telephonically weekly and as needed. • Attend patient/family care conferences. • Assess and monitor patients' continued appropriateness for SNF setting according to CMS criteria. • Coordinate peer to peer reviews with H&C Transitions Medical Directors. • Support new delegated contract start-ups to ensure experienced staff work with new contracts. • Manage assigned caseload efficiently and effectively utilizing time management skills. • Enter timely and accurate documentation into coordinate. • 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 to assist with the identification of opportunities for improvement. • Adhere to organizational and departmental policies and procedures. • Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws. • Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business. • Engage and collaborate with in-market leaders as needed based on current assignment or as directed by leadership. • 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. • Perform other duties and responsibilities as required, assigned, or requested. Requirements • Active, unrestricted registered clinical license required in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist. • May be required to pursue and maintain multi-state licensure to meet business needs. • 5+ years of clinical experience, in good standing with 1+ year of employment with H&C Transitions (1+ year of experience in Care Coordinator, Onsite role). Nice-to-haves • Experience working with the geriatric population. • Patient education background, rehabilitation, and/or home health nursing experience. • Familiarity with care management, utilization/resource management processes and disease management programs. • Proficient with Microsoft Office applications including Outlook, Excel, and PowerPoint. • Ability to prioritize, plan, and handle multiple tasks/demands simultaneously. • Detail-oriented. • Team player. • Exceptional verbal and written interpersonal and communication skills. • Solid problem solving, conflict resolution, and negotiating skills. • Independent problem identification/resolution and decision-making skills. Benefits • Comprehensive benefits package. • Incentive and recognition programs. • Equity stock purchase. • 401k contribution. Apply tot his job