The Optum Care at Home program provides ongoing support for Dual Eligible Special Needs Plan (D-SNP) members with Medicare and Medicaid benefits. Through individualized care planning and targeted interventions, the program helps address complex clinical, behavioral, functional, and social needs while supporting members in their preferred care setting.
As a Telephonic RN Case Manager, you will serve as a primary point of contact for members with complex medical, behavioral health, functional, social, and long-term services and supports needs. You will conduct telephonic assessments, develop person-centered care plans, coordinate transitions and community-based services, resolve barriers to care, and support members in remaining safely in their preferred setting whenever possible.
This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. solid computer and software navigation skills are critical. You should also be solidly patient-focused and adaptable to changes.
Schedule: Monday through Friday, daytime business hours. Candidates must be available to support operations across Mountain and Pacific Time Zones. This position will cover Washington and Colorado markets.
You will work remotely in Washington. Employees expected to attend in-person staff meetings at least quarterly.
Primary Responsibilities
- Conduct comprehensive telephonic assessments of members' medical, behavioral health, functional, psychosocial, caregiver, environmental, and socioeconomic needs
- Develop, implement, and reassess individualized, person-centered care plans that reflect each member's goals, preferences, risks, strengths, and desired level of independence
- Coordinate care across Medicare, Medicaid, primary and specialty care, behavioral health, pharmacy, home health, long-term services and supports, and community-based programs
- Identify gaps in care and barriers to treatment, including transportation, food insecurity, housing instability, caregiver needs, financial concerns, medication access, and health literacy, and connect members with appropriate resources
- Facilitate safe transitions between hospitals, skilled nursing facilities, rehabilitation settings, home health, and the member's residence, including timely follow-up with members, caregivers, and treating providers
- Assess changes in condition, apply clinical judgment and approved escalation pathways, and partner with assigned care managers, utilization management, market leadership, and clinical teams to address urgent or complex needs
- Respond to and support resolution of member escalations involving state Medicaid agencies, health care authorities, managed care organizations, health systems, members, families, caregivers, and other stakeholders
- Provide education on conditions, medications, warning signs, self-management, preventive care, and available benefits while using clear, culturally responsive, member-centered communication
- Advocate for members and caregivers so their needs, choices, rights, and preferences are represented in care planning and service delivery
- Support advance care planning discussions and connect members with appropriate clinical or community resources consistent with program guidelines
- Document assessments, care plans, interventions, referrals, outreach attempts, outcomes, and required data accurately and promptly in designated electronic health record and care management systems
- Use evidence-based practice standards, medical necessity criteria, and applicable Medicare, Medicaid, contractual, legal, and regulatory requirements when coordinating services
- Maintain required RN licensure, continuing education, and role-related credentials
Required Qualifications
- Active, unrestricted RN license or multistate RN license with legal authority to practice for members located in Washington by the position start date, with the ability to obtain Colorado RN licensure within required timeframe following start date
- 2+ years of professional RN experience
- Experience coordinating care for patients or members with complex or high-risk medical, behavioral health, functional, or social needs
- Experience with Medicaid Long-Term Services and Supports (LTSS), Home- And Community-Based Services, or a closely related Medicaid care management program
- Experience in case management, managed care, community health, home health, ambulatory care, population health, transitions of care, or another setting involving longitudinal care coordination
- Proficiency documenting in electronic health records or care management platforms and navigating multiple computer applications while speaking with members by phone
- Driver's License and access to reliable transportation
Preferred Qualifications
- Certified Case Manager (CCM) certification or another relevant case management credential
- Knowledge of Washington or Colorado Medicaid programs, health care systems, and community organizations serving older adults, people with disabilities, and individuals with complex needs
- Experience coordinating long-term care, personal care services, private duty nursing, home health, or other home- and community-based services
- Experience with utilization management, utilization review, discharge planning, concurrent review, or risk management
- Experience working effectively with interdisciplinary teams in a remote or telephonic care management environment
- Reside in Washington
The salary for this role will range from $91,500 to $137,300 annually based on full-time employment. We comply with all minimum wage laws as applicable.