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The Optum Dual Special Needs Plan (DSNP) 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 Optum trained clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, which includes the Optum clinician, the member's Primary Care Provider and other providers, and other professionals.

The Field Registered Nurse supports the overall patient care management process for members in In-Home DSNP program. The Field Registered Nurse provides oversight, guidance and support for the patient care plan as developed in collaboration with the interdisciplinary care team along with the health plan and additional heath care vendors to meet the needs of the patient. The Field RN coordinates and provides appropriate levels of care under the direct supervision of an RN/APC or MD. This position is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, in home visit assessments, coordination of care, and medical management consulting. The Field RN will also be responsible for home visits, transition of care management, providing health education, coaching and treatment decision support for members in At Home DSNP program.

This is a field-based position based in Milwaukee, WI.

Position Highlights & Primary Responsibilities

• Perform initial review of consumer health records and current health status (e.g., health risk scores) to identify health risk and determine next steps
• Conduct initial and ongoing assessments utilizing nursing assessment skills in home setting
• Receive information from consumers about specific symptoms and questions
• Conduct interviews to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy
• Evaluate consumer data throughout the assessment process to identify inconsistencies and adherence to Evidence Based Guidelines from both the health care and psychosocial / socioeconomic dimensions of care
• Identify and prioritize gaps to develop plan of care and short and long term goals to empower consumers to meet identified goals
• Determine consumer's willingness to engage in plan of care and readiness for change
• 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 format
• 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 standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results

Required Qualifications

• Active, un-encumbered RN license
• 3+ years of experience in a hospital, acute care or direct care setting
• Experience with EMR systems and navigating a Windows based environment
• Driver's license and access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area

Preferred Qualifications

• BSN
• CCM
• Case Management experience
• Experience working in home health or in home setting
• Experience with chronically ill patients and families
• Understanding of Medicare, Medicaid and Health Plan benefit structures

The salary for this role will range from $60,200 - $107,400 annually based on full-time employment.