Care Coordinator, Onsite - Chesterton

About the Role

Optum Home & Community Care, part of United Health Group, is creating a new integrated care model that addresses patients’ physical, mental, and social needs. As a member of the navi Health product, the Care Coordinator‑Onsite supports patients as they transition from hospital to home, helping older adults stay in the community longer. This hybrid position requires four in‑office days per week.

• Serve as the link between patients, families, and appropriate health‑care personnel to ensure smooth, efficient, and timely transitions of care.
• Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and CMS criteria upon admission and periodically throughout the stay.
• Review target outcomes, and discharge plans with providers and families.
• Complete all SNF concurrent reviews, updating authorizations promptly.
• Collaborate with the patient’s health‑care team (physicians, referral coordinators, discharge planners, social workers, PT/OT, etc.) to establish an optimal discharge plan.
• Assure patients’ progress toward discharge goals and assist in resolving barriers.
• Participate weekly in SNF rounds, providing accurate information to the H&C Transitions Senior Manager or Medical Director.
• Ensure 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 settings according to CMS criteria.
• When delegated for utilization management, review referral requests that cannot be approved for continued stay and forward them to licensed physicians for review, issuing NOMNC when appropriate.
• Coordinate peer‑to‑peer reviews with H&C Transitions Medical Directors.
• Support new delegated contract start‑ups, ensuring experienced staff cover new contracts.
• Manage assigned caseload efficiently, using time‑management skills.
• Enter timely and accurate documentation.
• Review daily census, identify barriers, and support workload management.
• Review monthly dashboards, readmission reports, quarterly reports, etc. with the Clinical Team Manager to identify improvement opportunities.
• Adhere to organizational and departmental policies and procedures.
• Maintain confidentiality of all PHI in compliance with HIPAA, federal, and state regulations.
• Complete cross‑training and maintain knowledge of multiple contracts/clients for coverage support.
• Stay current on federal and state regulatory policies related to utilization management and care coordination (CMS guidelines, Health Plan policies).
• Promote a positive attitude and work environment.
• Attend H&C Transitions meetings as requested.
• Keep PHI confidential per applicable laws and institutional policies.
• Perform other duties as required, assigned, or requested.

• Active, unrestricted registered clinical license in the state of hire (Registered Nurse, Physical Therapist, Occupational Therapist, or Speech‑Language Pathologist).
• At least 5 years of clinical experience.
• Ability to support specific location(s) for on‑site facility needs within a 30‑mile radius of home location, based on manager discretion.
• Residence within the county listed in the job description.
• Driver’s license and reliable transportation.

• Experience working with the geriatric population.
• Familiarity with care management, utilization/resource management processes, and disease‑management programs.
• Background in patient education, rehabilitation, and/or home health nursing.
• Proficiency with Microsoft Office (Outlook, Excel, PowerPoint).
• Detail‑oriented, with proven ability to prioritize,…