This function is for UHC C & S. Positions in this function address efforts focused on medical, behavioral, and social determinants of health that improve the well-being of individuals, families, and communities. As an HSS Clinical Quality Coordinator, you will be responsible for, coordinating care for members transitioning from an inpatient hospital setting to home or another level of care. The role focuses on developing individualized plans of care, identifying barriers to successful recovery, and reducing potentially preventable hospital readmissions through proactive assessment, education, and care coordination. This is a fast-paced working environment that requires the ability to multitask with attention to detail and excellent organizational skills.
If you reside within the state of Texas, you will enjoy the flexibility to telecommute* as you take on some tough challenges.
Primary Responsibilities
- Conduct post-discharge outreach and interventions to reduce potentially preventable readmissions while meeting contractual obligations per state regulatory requirement
- Assess, plan and implement care strategies that are individualized by member and directed toward the most appropriate, lease restrictive level of care
- Discuss discharge planning to ensure understanding and assist in ensuring all ordered services are arranged prior to discharge Assist members with obtaining necessary HCBS support and services
- Coordinate with physicians, hospital case managers, discharge planners, caregivers and community resources to ensure continuity of care
- Utilize both company and community-based resources to establish a safe and effective case management plan for members while leveraging evidence-based guidelines
- Collaborate with member, family, and healthcare providers to develop an individualized plan of care
- Work with members to identify potential barriers to achieving healthcare goals and outcomes
- Identify and initiate referrals for specialized case management programs, social service programs, including financial, psychosocial, community, and state supportive services
- Resolve barriers to in-home care, transportation, medical or medications and find alternatives for additional support if needed
- Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members
- Advocate for patients and families as needed to ensure the patient's needs and choices are fully represented and supported by the healthcare team
- Document all member assessments, care plan and referrals provided
- Participate in Interdisciplinary team meetings/rounds and provide information to support members individualized needs
- Understand insurance products, benefits, coverage limitations, and governmental regulations as it applies to the health plan
- Understand role and how it affects utilization and quality outcomes including reducing potentially preventable events
- Provide, arrange, and coordinate preventive, primary, acute care, behavioral health and pharmacy services that contribute to the well-being of the member
- Review medical records for compliance with regulatory guidelines (e.g., NCQA, state Medicaid contracts, and compliance)
- Work with internal partners to create a culture of health and wellness that promotes member health
- Provide individualized education on preventative healthcare measures (e.g., immunization, healthcare screening) to close quality gaps in care
Required Qualifications
- Active LVN license in the state of Texas
- 2+ years of experience working with electronic health records
- 2+ years of experience working with Medicaid/Medicare members with complex medical or behavioral needs
- Intermediate level of proficiency with MS Office applications
Preferred Qualifications
- 2+ years' experience diversified clinical nursing experience, including medical/surgical, case management or discharge planning
- Knowledge of quality metrics, pay for quality or HEIDIS measures
- Demonstrated ability to assist with achieving targets, including productivity and certain metrics
- Previous experience working in a telecommute role
*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.
The hourly pay for this role will range from $24.00 to $43.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.