Registered Nurse Field Case Manager - Care at Home - DC, MD, VA

 $5,000 Sign-on Bonus for External Candidates

Optum Home & Community Care, part of the Optum 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 Care at Home team, 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. This life-changing work adds a layer of support to improve access to care. We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

The Optum Care at Home program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of members in their place of residence. The DSNP program combines clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, which includes the clinician, the member's Primary Care Provider and other providers, and other professionals. 

This position is open to candidates who live in DC, MD, or VA

This is a field-based position in the greater Washington D.C. area.

Expect to spend about 50-75% of your time in the field visiting our members in their homes or in long-term care facilities in the local area. 

You'll need to be flexible, adaptable and, above all, patient in all types of situations.

Standard Hours:  Monday - Friday normal daytime business hours (no on-call, no weekends and no holidays required).

Primary Responsibilities:

• Assess, plan and implement care management interventions that are individualized for each member and directed toward the most appropriate, least restrictive level of care
• Develop and implement care plan interventions throughout the continuum of care as a single point of contact
• Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members
• Advocate for members and families as needed to ensure the member's needs and choices are fully represented and supported by the health care team
• Identify appropriate interventions and resources to meet gaps (e.g., psychosocial, transportation, long-term care) based on specific consumer needs from both the health care and psychosocial / socioeconomic dimensions of care
• Document the plan of care in appropriate EHR systems and enter data per specified
• Maintain consumer engagement by establishing rapport, demonstrating empathy, and building a trusting relationship
• Collaborate with primary providers or multidisciplinary team to align or integrate goals to plan of care and drive consistent coordination of care
• Provide ongoing support for advanced care planning
• Reassess plan of care at appropriate intervals based on initial objectives, significant change of condition, or achievement of goals
• Understand and operate effectively/efficiently within legal/regulatory requirements
• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standard)
• Make outbound calls and receive inbound calls to assess members' current health status
• Identify gaps or barriers in treatment plans
• Provide member education to assist with self-management
• Make referrals to outside sources
• Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction
• Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels

You'll 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:

• Current unrestricted Registered Nurse license in Washington D.C., or the ability to obtain within 90 d