Care Coordinator - Onsite, Beverly​/Peabody, MA Hybrid, RN​/PT​/OT​/ST

Optum Home & Community Care, part of the United Health Group 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 navi Health product, we help change the way health care is delivered from hospital to home supporting patients transitioning across care settings. This life-changing work helps give older adults more days at home.

We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

The Care Coordinator
- Onsite plays an integral role in optimizing patients' recovery journeys. The Care Coordinator
- Onsite completes weekly functional assessments and engages the post-acute care (PAC) inter-disciplinary care team to coordinate discharge planning to support the members PAC journey. The position engages patients and families to share information and facilitate informed decisions. By serving as the link between patients and the appropriate health care personnel, the Clinical Review Coordinator
- Onsite is responsible for ensuring efficient, smooth, and prompt transitions of care.

At navi Health, our mission is to work with extraordinarily talented people who are committed to making a positive and powerful impact on society by transforming health care. navi Health is the result of almost two decades of dedicated visionary leaders and innovative organizations challenging the status quo for care transition solutions. We do health care differently and we are changing health care one patient at a time.

Moreover, have a genuine passion and energy to grow within an aggressive and fun environment, using the latest technologies in alignment with the company's technical vision and strategy.

This position follows a hybrid schedule with four in-office days per week.

• By serving as the link between patients and the appropriate health care personnel, the Care Coordinator
  - Onsite is responsible for ensuring efficient, smooth, and prompt transitions of care
• Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays
• Review target outcomes, and discharge plans with providers and families
• Complete all SNF concurrent reviews, updating authorizations on a timely basis
• Collaborate effectively with the patients' health care teams to establish an optimal discharge. The health care team includes physicians, referral coordinators, discharge planners, social workers, physical therapists, etc.
• Assure patients' progress toward discharge goals and assist in resolving barriers
• Participate weekly in SNF Rounds providing accurate and up to date information to the H&C Transitions Sr. Manager or Medical Director
• Assure appropriate referrals are made to the Health Plan, High-Risk Case Manager, and/or community-based services
• Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed
• Attend patient/family care conferences
• Assess and monitor patients' continued appropriateness for SNF setting (as indicated) according to CMS criteria
• When H&C Transitions is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forward to licensed physicians for review and issuance of the NOMNC when appropriate
• Coordinate peer to peer reviews with H&C Transitions Medical Directors
• Support new delegated contract start-up to ensure experienced staff work with new contracts
• Manage assigned caseload in an efficiently and effectively utilizing time management skills
• Enter timely and accurate documentation into coordinate
• Daily review of census and identification of barriers to managing independent workload and ability to assist others
• Review monthly dashboards, readmission reports, quarterly, and other reports with the assigned Clinical Team Manager, as needed, to assist with the identification of opportunities for improvement
• Adhere to organizational and departmental policies and procedures
• Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws
• Complete cross-training and maintain knowledge of multiple contracts/clients to support coverage needs across the business
• Keep current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies, and benefits)
• Adhere to all local, state, and federal regulatory policies and procedures
• Promote a positive attitude and work environment
• Attend H&C Transitions meetings as requested
• Hold patients' protected health information confidential as required by applicable laws, regulations, or agency/institution procedures
• Perform other duties and…