Care Coordinator, Onsite - Claremore, OK; Hybrid - RN​/PT​/OT​/ST

Optum Home & Community Care, part of the Optum 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 Optum Care at Home team, together with an interdisciplinary care team we help patients navigate the health care system and connect them to key support services.

This preventive care can help patients stay well s life-changing work adds a layer of support to improve access to care. We’re connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

The Onsite Care Coordinator plays an integral role in optimizing patients’ recovery journeys. The Care Coordinator 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 Care Coordinator is responsible for ensuring efficient, smooth, and prompt transitions of care.

• By serving as the link between patients and the appropriate health care personnel, the Care Coordinator is responsible for ensuring efficient, smooth, and prompt transitions of care
• Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed. Collaborate effectively on discharge goals and assist in resolving barriers
• Collaborate effectively with members health care teams with individualized communication and participation in interdisciplinary team meetings
• Review target outcomes and discharge plans with providers and families
• 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
• Assess and monitor patients’ continued appropriateness for SNF setting (as indicated) according to CMS criteria
• Complete all SNF continued stay reviews, updating authorizations on a timely basis
• When Care Transitions is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forwarded to licensed physicians for review and issuance of the NOMNC when appropriate
• Perform other duties and responsibilities as required, assigned, or requested

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

• Active, unrestricted registered clinical license required in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist
• 2+ years of clinical experience
• Ability to support specific location(s) for on-site facility needs within 30-mile maximum radius of home location based on manager discretion
• Reside within or near the county listed in the job description
• Ability to mobilize to and within sites within an assigned local or regional market/area, including car transport, up to 85% of the time
• Driver’s License and access to reliable transportation

• Demonstrated familiarity with care management, utilization/resource management processes and disease management programs
• Proficient with Microsoft Office applications including Outlook, Excel and Power Point
• Experience working with the geriatric population
• Demonstrated patient education background, rehabilitation, and/or home health nursing experience

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k…