The primary purpose of this position is the application of clinical knowledge to coordinate member care needs for assigned members who are primarily medically complex and require intensive medical and psychosocial support. The Care Coordinator works directly with members to ensure appropriate access to services and providers. Coordination of member care needs across the continuum begins with early identification of health risk factors, education, and prevention using the six essential activities of case management as per CMSA. Coordination also assures the provision of appropriate services in acute, home, chronic and alternative care settings, to meet member needs in the most cost-effective manner available. Collaborates with all members of the Care Coordination team including Case Management, Utilization Review and Behavioral Health team members.
If you are located in or within commutable driving distance to Grain, Camplin, Cocke, & Jefferson counties, you'll enjoy the flexibility to work remotely* as you take on some tough challenges. This is a field-based role.
Primary Responsibilities:- Application of clinical knowledge to effect efficient case management for those accessing their Medicare/Medicaid benefits
- Incorporates evidence-based clinical practices into care coordination activities
- Delivers member-centered, individualized self-management support and patient education
- Ensure appropriate utilization and consistent application of the health benefits
- Conduct telephonic and face to face assessments according to Health Plan policy and procedure, including system documentation and State prescribed timeframes
- Serve as member advocate and facilitator to resolve issues that may be perceived as barriers to care
- Provide education and coordination of community resource referrals to members and providers
- Develop, implement, maintain and evaluate a member-centered, individual care plan when services are indicated, based on member care needs identified through proactive collaboration and communication with members, families and providers
- Collaborate and communicate with other members of the Care Coordination Team to improve the quality and efficiency of health care delivery and ensure smooth transition of care coordination activities to other team members
- Monitor hospital encounters of assigned members and provide education and/or interventions as necessary to reduce frequency
- Refer clinical decisions beyond level of authority for members who do not meet established criteria to manager for review and decision
- Participate in the Health Plan Quality Improvement process including recognition of quality-of-care issues and forward information to appropriate staff for review and resolution
- Utilize Health Plan software to enter service requests, document, and monitor all aspects of member care coordination and service delivery
- Maintain time sensitive documentation to assure compliance with regulatory agencies
- Coordinate services for members following Health plan policy
- Perform other duties as assigned
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- Current Nursing license (RN)
- 2+ years of clinical experience as an RN
- 1+ years of experience with MS Office, including Word, Excel, and Outlook
- Excellent organization, communication and time management skills
- Reside in or within a commutable driving distance to Grain, Camplin, Cocke, & Jefferson Counties
- Access to reliable transportation and valid US driver's license with the ability to travel up to 75% within an assigned territory to meet with members and providers
Preferred Qualifications:- BSN, Master's degree in Clinical Field
- CCM certification
- 1+ years of community case management experience coordinating care for individuals with complex needs
- Long term care experience
- Experience working in team-based care
- Working knowledge of Medicare/Medicaid regulations
- Working knowledge of medical terminology
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
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 $29 - $52 per hour based on full-time employment. We comply with all minimum wage laws as applicable.
