$10,000 Sign-on Bonus for External CandidatesNo on-call, no weekends, and no holidays required.This role supports Optum Senior Community Care's
SNF Patient Connect Program, a unique, one-time visit initiative designed for UnitedHealthcare members transitioning from hospitalization to a skilled nursing facility (SNF) and ultimately back home. The program focuses on improving care transitions, reducing 30-day hospital readmissions, and enhancing overall patient outcomes during a critical stage in the healthcare journey.
In this autonomous role, the Advanced Practice Clinician (APC) conducts a comprehensive, one-time health assessment in collaboration with the case management team to support effective care coordination. The visit emphasizes accurate and complete documentation of acute and chronic conditions, improved coding accuracy, and increased closure of STAR/HEDIS quality measures, including support for Advanced Care Planning directives.
The APC plays a key role in educating patients and supporting both patients and families during a vulnerable transition period, while also communicating pertinent findings to attending providers and facility staff. Unlike traditional clinical roles, the APC does not manage ongoing care or carry responsibility for orders, treatments, or follow-up, allowing greater focus on assessment, insight, and impact.
This position offers the opportunity to work independently across varied care settings, leveraging clinical expertise to improve patient satisfaction, strengthen discharge planning, and enhance post-discharge support. It is a highly rewarding role for clinicians seeking autonomy while making a meaningful difference in the lives of a complex patient population.
Primary Responsibilities:- Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements and Center for Medicare and Medicaid Services (CMS) regulations
- Responsible for ensuring that all diagnoses are ICD10, coded accurately, and documented appropriately to support the diagnosis at that visit
- The APC is responsible for ensuring that all quality elements are addressed and documented
- The APC will do an initial medication review
- Must attend and complete all mandatory educational and computer/virtual training requirements
- Travel between care sites mandatory
- Care Coordination
- Communicate with the patient and necessary team members regarding any medical concerns at the time of your visit
- Program Enhancement Expected Behaviors
- Exhibit original thinking and creativity in the development of new and improved methods and approaches to concerns/issues
- Function independently and responsibly with minimal need for supervision
- Ability to enter available hours into web-based application, at least one month prior to available work time
- Demonstrate initiative in achieving individual, team, and organizational goals and objectives
- Participate in SCC quality initiatives
- Availability to check Optum email intermittently for required trainings, communications, and monthly scheduling
You9ll 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:- For NPs: Active ANCC or AANP certification in Family, Adult, Geriatric, or Adult-Gerontology Primary Care
- For PAs: Current NCCPA certification and state licensure
- Active, unrestricted licensure in the state you will be practicing in (or ability to obtain by start date) without current disciplinary actions or practice limitations
- Active and unrestricted driver9s license
- In addition to a driver9s license, access to reliable transportation
- Ability to gain a collaborative practice agreement, if applicable in your state
- Availability to work 40 hours per week
- Ability to move a 30-pound bag in and out of car and to navigate stairs and a variety of dwelling conditions and configurations
- Ability to navigate varied environments and to position oneself as needed to perform job duties
- Proficient computer skills including the ability to document medical information with written and electronic medical records
Preferred Qualifications:- 1+ years of clinical experience as an APC (long-term care setting preferred)
- Experience in geriatric medicine, long-term care, senior living or home care setting
- Experience in meeting the medical needs of patients with complex behavioral, social and/or functional needs
- Understanding of Geriatrics and Chronic Illness
- Understanding of Advanced Illness and end of life discussions
- Proficiency with electronic medical records and technology
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, you9ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $91,700 to $163,700 annually based on full-time employment. We comply with all minimum wage laws as applicable.
