Nurse Case Manager - Transition Of Care

Optum UT is seeking a Registered Nurse to join our team in UT. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you'll be an integral part of our vision to make healthcare better for everyone.

At Optum, you'll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. We believe you deserve an exceptional career, and will empower you to live your best life at work and erience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country.

Because together, we have the power to make health care better for everyone. Join us in improving healthcare through the power of people and intelligent technologies while Caring. Connecting. Growing together.

The Transition of Care (TOC) Registered Nurse is telephonic and is responsible for coordinating and managing care for members transitioning from observation, inpatient, skilled nursing, and other post-acute settings. The RN works collaboratively with patients, caregivers, providers, Community Health Workers, and interdisciplinary teams to support safe transitions, address barriers to recovery, reduce avoidable hospital readmissions and emergency department utilization, and improve overall health outcomes.

Candidate must live and possess an active and unrestricted Utah RN license

If you are located in Utah, you will have the flexibility to work remotely
* as you take on some tough challenges.

• Assess, develop, implement, and monitor individualized care plans for discharged acute care patients and high-risk Medicare Advantage patients
• Manage a caseload and conduct comprehensive clinical assessments to identify medical, functional, psychosocial, and environmental factors that may impact recovery and health outcomes
• Complete timely outreach to eligible patients following hospitalization, emergency department visits, or post-acute care stays in accordance with organizational standards
• Evaluate discharge plans and address barriers that may interfere with recovery, treatment adherence, or successful transition to the community
• Perform medication reconciliation and identify potential medication-related concerns requiring intervention or provider follow-up
• Engage patients and caregivers in care planning, provide education, and promote self-management to support successful transitions and improved outcomes
• Coordinate care across healthcare settings and providers, including primary care providers, specialists, hospitals, skilled nursing facilities, home health agencies, and community resources
• Collaborate with Community Health Workers and interdisciplinary team members to address social determinants of health and other non-clinical barriers impacting care
• Facilitate timely primary care, specialty care, and post-discharge follow-up appointments, if indicated
• Monitor patient progress throughout the transition period and modify interventions as necessary to address changing needs
• Identify patients at risk for avoidable emergency department utilization, hospital readmissions, or adverse outcomes and implement appropriate interventions
• Communicate and collaborate effectively with patients, caregivers, providers, and interdisciplinary teams to ensure continuity of care
• Maintain accurate, timely, and complete documentation in accordance with organizational, regulatory, and accreditation requirements
• Adhere to all applicable policies, procedures, HIPAA regulations, and quality standards
• Participate in performance improvement, care coordination, and…