Field RN Case Manager, Care

$5,000 Sign On Bonus For External Candidates

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 in an interdisciplinary care environment, 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 in improving healthcare through the power of people and intelligent technologies while Caring. Connecting. Growing together.

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.

• 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

You’ll be rewarded and recognized for your…