Care Coordinator, Onsite Optum Home & Community Care, part of the Optum family of businesses, is creating something new in healthcare. By bringing together industry-leading solutions, advanced technology and compassionate teams, we are building a more connected experience that helps address an individual's physical, mental and social needs. As a team member of our Optum Care Transitions team, you'll help patients navigate the healthcare system, access the support and services they need, and receive the right care at the right time. This meaningful work is helping improve health outcomes, expand access to care and create a more seamless health journey for the people we serve. Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together. The Care Coordinator, Onsite plays an integral role in optimizing patients' recovery journeys. 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. Primary Responsibilities: Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed. Collaborate effectively on discharge goals and assist in resolving barriers Collaborate effectively with members health care teams with individualized communication and participation in interdisciplinary team meetings Review target outcomes and discharge plans with providers and families 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 Assess and monitor patients' continued appropriateness for SNF setting (as indicated) according to CMS criteria Complete all SNF continued stay reviews, updating authorizations on a timely basis When Care Transitions is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forwarded to licensed physicians for review and issuance of the NOMNC when appropriate Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business Manage assigned caseload efficiently and effectively utilizing time management skills Enter timely and accurate documentation into Coordinate Adhere to organizational and departmental policies and procedures Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws 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 Attend Care Transitions meetings as requested Promote a positive attitude and work environment Perform other duties and responsibilities as required, assigned, or requested Required Qualifications: Active, unrestricted registered clinical license required in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist Candidate hired will support specific location(s) for on-site facility needs within 30-mile maximum radius of home location based on manager discretion 5+ years of clinical experience Reside within or near the county listed on the job description Driver's License and access to a reliable transportation Preferred Qualifications: Patient education background, rehabilitation, and/or home health nursing experience Experience working with the geriatric population Familiarity with care management, utilization/resource management processes and disease management programs Proficient with Microsoft Office applications including Outlook, Excel and PowerPoint Proven to be detail-oriented Proven to be a team player Proven ability to prioritize, plan, and handle multiple tasks/demands simultaneously Proven exceptional verbal and written interpersonal and communication skills Proven solid problem solving, conflict resolution, and negotiating skills Proven independent problem identification/resolution and decision-making skills Work Conditions and Physical Requirements: Dedicated, distraction-free space in home for home office Access to high-speed internet from home (Broadband Cable, DSL, Fiber) Ability to manipulate laptop computer (or similar hardware) between office and site settings Ability to view screen and enter data into a laptop computer (or similar hardware) within a standard period of time Ability to communicate with clients and team members including use of cellular phone or comparable communication device Ability to remain stationary for extended time periods (1 - 2 hours) Ability to mobilize to and within sites within an assigned local or regional market/area, including car transport, up to 85% of the time About Home & Community Care Transitions H&C Care Transitions, part of Optum and the UnitedHealth Group family of businesses, combines the talents of our dedicated staff and leading-edge technology to deliver compassionate care to seniors nationwide. With millions of lives touched, we are innovating the way health care is delivered from hospital to home so seniors can lead more fulfilling lives. A career with us means making an impact in the lives of those we serve, including vulnerable populations who benefit from care that is more efficient, more effective, and more human. Our environment empowers our team members to elevate our interactions with each other and the experiences we deliver to our patients, giving them more days at home. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer 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 us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $35.00 - $63.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable. At UnitedHealth Group, our mission is to help people live healthier lives and help make the health system work better for everyone. Together, we are shaping the future of healthcare by harnessing technology and innovation to make care simpler to navigate, more affordable and more connected for the people we serve. We are committed to creating an inclusive workplace where everyone feels welcomed, valued, heard and respected, empowering people to bring their authentic selves to work and strengthening our collective impact through diverse talents, backgrounds, experiences and perspectives. UnitedHealth Group and its affiliated brands are an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations. UnitedHealth Group and its affiliated brands are a drug-free workplace. Candidates are required to pass a drug test before beginning employment.