Transitional Care Nurse Liaison

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities.

Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The Transitional Care Nurse is a registered nurse who provides comprehensive education, coaching and support to high-risk patients during transitions from acute care settings. In partnership with Boulder Community Health, this position focuses on readmission prevention through health education, chronic disease self-management, and connecting patients with appropriate care and community resources. By fostering a patient-centered partnership with the care team, the Transitional Care Nurse enhances the patient experience and collaborates to reduce unnecessary high-cost care for those with complex health needs.

The Transitional Care Nurse Liaison fosters relationships with area skilled nursing facilities, inpatient rehab hospitals, and other community partners.

Boulder Community Health (BCH) primary care physician clinics are guided by the philosophy of the Patient-Centered Medical Home. The medical home organizes care around patients, while engaging a multidisciplinary care team working proactively to coordinate and track care for each individual patient.

You will enjoy the flexibility to telecommute
* from anywhere within the U.S. as you take on some tough challenges.

• Using department methodology, identify patients for transitional care programs
• Conduct telephonic outreach to patient, family/caregiver, and/or facility to enroll in transitional care program. Conduct initial assessment and medication reconciliation per workflow
• Maintain an active panel of transitional care patients according to department procedures
• While patients are enrolled in transitional care, deliver ongoing care according to the treatment plan. Develop and document patient-centered goals and barriers to care
• Collaborate as a member of a care team with primary and specialty care providers, medical assistants, care managers, nurses, and other clinic staff to provide care to patients based on best practices
• Facilitate communication among care teams to address patient needs and barriers to care
• Provide patient education and community referrals for appropriate and timely care. Initiate and revise patient education resources and tools with BCH partner. Update patient records to reflect current condition, treatment plan, and assess/document patient understanding of treatment plan, medications and adherence to medication regimen
• Participate in regular and ad hoc team, department, company and BCH partner meetings and committees
• Contribute to readmission root cause analyses and quality improvement initiatives
• Maintain working knowledge of health laws, protocols, managed care contracts, and insurance and consider financial impacts to patients
• Perform effectively in stressful and/or emergency situations
• Periodically cross cover for other integrated clinical services staff
• Work is generally self-directed and not prescribed
• Work with less structured, more complex issues
• Identify solutions to non-standard requests and problems
• Solve moderately complex problems and/or conduct moderately complex analyses
• Work with minimal guidance; seeks guidance on only the most complex tasks
• Translate concepts into practice
• Provide explanations and information to…