RN Field Case Manager, Care - King, Pierce & Snohomish Counties, WA

Position: RN Field Case Manager, Care at Home - King, Pierce & Snohomish Counties, WA
$7,500 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 at home.  This 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 Care at Home (CAH) Dual Special Needs Plan (DSNP) program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of patients (beneficiaries) in their place of residence.

The CAH program combines Optum trained clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, comprised of the Care at Home team of clinicians as well as community-based health care professionals (e.g., PCP, specialists, behavioral health, pharmacy, and other providers). Optum providers serve people in their own homes through annual evaluations, longitudinal visits for higher risk beneficiaries, care coordination during transitions from the hospital or nursing home, and ongoing care management.

Registered Nurses (RNCM) in the Care at Home program work with patients primarily in their home setting. They perform as part of a care team including a Nurse Practitioner, Behavioral Health Advocate, Care Navigator and other supporting team members.  They deliver role appropriate patient care through in-home visits, telephonic outreach and consultations, and interdisciplinary team activities. The RNCM may provide care, initiate and update care plans, and provide education and counsel patients in the promotion and maintenance of health throughout the life span.

The RNCM helps manage health problems (including medical, behavioral, and SDOH) and coordinate health care for the Care at Home patients in accordance with State and Federal rules and regulations and the nursing standards of care. This includes (but is not limited to) assessment of health status, development and implementation of plan of care, and ongoing evaluation of patient status and response to the plan of care.

Clinical management is conducted in collaboration with other care team members. Position Highlights &

Primary Responsibilities:

Assess the health status of patients within the scope of licensure and with the frequency established in the model of care Establish goals to meet identified health care needs

Plan, implement, and evaluate responses to the plan of care

Work collaboratively with the interdisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care Works closely with mental health clinicians to help bridge the gap between mental and physical health

Review Daily on Call Report to monitor assigned patients calling into Urgent Care and schedule with APC/RN as clinically indicated

Consult with the patient's PCP, specialists, or other health care professionals as appropriate

Assess patient needs for community resources and make appropriate referrals for service

Facilitate the patient's transition within and between health care settings in collaboration with the primary care physician and other treating physicians

Complete and accurately document in patient's electronic medical record

Provide patients and family members with counseling and education regarding health maintenance, disease prevention, condition trajectory and need for follow up as appropriate during each patient visit

Verify and document patient and/or family understanding of condition, plan of care and follow up recommendations

Actively participate in organizational quality initiatives Participate in collaborative interdisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery

Initiate internal and external referrals as clinically indicated

Maintain credentials essential for…