RN Field Case Manager, Care at Home - Berks & Chester Counties, PA

$5,000 Sign-on Bonus for External Candidates

The Care at Home (CAH) Dual Special Needs Plan (DSNP) program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of patients (beneficiaries) in their place of residence. The CAH program combines Optum trained clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, comprised of the Care at Home team of clinicians as well as community-based health care professionals (e.g., PCP, specialists, behavioral health, pharmacy, and other providers). Optum providers serve people in their own homes through annual evaluations, longitudinal visits for higher risk beneficiaries, care coordination during transitions from the hospital or nursing home, and ongoing care management.

Registered Nurses (RNCM) in the Care at Home program work with patients primarily in their home setting. They perform as part of a care team including a Nurse Practitioner, Behavioral Health Advocate, Care Navigator and other supporting team members. They deliver role-appropriate patient care through in-home visits, telephonic outreach and consultations, and interdisciplinary team activities.

The RNCM may provide care, initiate and update care plans, and provide education and counsel patients in the promotion and maintenance of health throughout the life span. The RNCM helps manage health problems (including medical, behavioral, and SDOH) and coordinate health care for the Care at Home patients in accordance with State and Federal rules and regulations and the nursing standards of care. This includes (but is not limited to) assessment of health status, development and implementation of plan of care, and ongoing evaluation of patient status and response to the plan of care. Clinical management is conducted in collaboration with other care team members.

Primary Responsibilities

• Assess the health status of patients within the scope of licensure and with the frequency established in the model of care
• Establish goals to meet identified health care needs
• Plan, implement, and evaluate responses to the plan of care
• Work collaboratively with the interdisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care
• Works closely with mental health clinicians to help bridge the gap between mental and physical health
• Review Daily on Call Report to monitor assigned patients calling into Urgent Care and schedule with APC/RN as clinically indicated
• Consult with the patient's PCP, specialists, or other health care professionals as appropriate
• Assess patient needs for community resources and make appropriate referrals for service
• Facilitate the patient's transition within and between health care settings in collaboration with the primary care physician and other treating physicians
• Complete and accurately document in patient's electronic medical record
• Provide patients and family members with counseling and education regarding health maintenance, disease prevention, condition trajectory and need for follow up as appropriate during each patient visit
• Verify and document patient and/or family understanding of condition, plan of care and follow up recommendations
• Actively participate in organizational quality initiatives
• Participate in collaborative interdisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery
• Initiate internal and external referrals as clinically indicated
• Maintain credentials essential for practice, to include licensure, certification (if applicable) and CEUs
• Demonstrate a commitment to the mission, core values and goals of UnitedHealthcare and its healthcare delivery including the ability to integrate values of compassion, integrity, performance, innovation and relationships in the care provided to our patients

Required Qualifications

• Active unrestricted RN licensure in state of residence and state of assignment
• 2+ years of relevant experience
• Experience in assessing the medical needs of patients with complex behavioral, social and/or functional needs
• Ability to work with diverse care teams in a variety of settings including non-clinical settings (primarily patient homes)
• Ability to travel up to 75% of the time for field-based work; valid driver's license
• Ability to physically navigate home settings, lift 30 pounds, reliable transportation for commuting to member homes
• Solid computer skills, including use of Electronic Medical Records

Preferred Qualifications

• Bilingual in English & Spanish
• Experience in home health care or hospice setting
• Certified Case Management (CCM) Certification
• Experience in home health care or hospice setting
• Effective time management and communication skills

The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.