RN Case Manager - Seattle - Field Remote

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 At Home product, together with an interdisciplinary care team we help patients navigate the health care system, and connect them to key support services. This preventive care can help patients stay well 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.

Under minimal supervision, responsible for ensuring the continuity of care in the outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing advanced nursing knowledge, experience and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site and telephonically as the need arises. Works in conjunction with the care team and PCP as care team leader to develop a patient centered plan of care.

Prioritizes patient care needs upon initial visit and addresses emerging issues Meets with patients, patients’ family and caregivers as needed to discuss care and treatment plan Identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings Consults with physician and other team members to ensure that care plan is successfully implemented Coordinates treatment plans with the care team and triages interventions appropriate to the skill set of the team members. Uses protocols and pathways in line with established disease management and care management programs in order to optimize clinical outcomes and minimize unnecessary institutional care Monitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-management Oversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc. in order to maintain continuity of care Works in coordination with the care team and demonstrates accountability with patient management and outcome Discusses Durable Power of Attorney (DPOA) and advanced directive status with patient and PCP when applicable Maintains effective communication with the physicians, hospitalists, extended care facilities, patients and families Provides accurate information to patients and families regarding resources available to them through health plan benefits, community resources, and referrals Participates actively in Monthly Care Management Department meetings and daily huddles Documents pertinent patient information and Care Management Plan in Electronic Health Record Coordinates care with central departments on assigned patient caseload, including, inpatient, long term care facilities, adult family homes, and home health agencies Demonstrates a thorough understanding of the cost consequences resulting from Care Management decisions through utilization reports and systems such as Health Plan Benefits, CM dashboards and reports Maintains concise and accurate documentation that supports effective and efficient management of care plans to decrease Emergency and hospital readmissions