Registered Nurse - Field Visit Clinical RN - Optum - Washington D.C.

Position: Registered Nurse - Initial Field Visit Clinical RN - Optum at Home - Washington D.C.
**$5,000 Sign-on Bonus for External Candidates*
* For those who want to invent the future of health care, here's your opportunity. We're going beyond basic care to health programs integrated across the entire continuum of care.  
** Join us to start Caring. Connecting. Growing together.*
* You push yourself to reach higher and go further. Because for you, it's all about ensuring a positive outcome for patients. In this role, you'll work in the field and coordinate the long-term care needs for patients in the local community. And at every turn, you'll have the support of an elite and dynamic team. Join United Health Group and our family of businesses and you will use your diverse knowledge and experience to make health care work better for our patients.

The United Healthcare 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 clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, which includes the clinician, the member's Primary Care Provider and other providers, and other professionals.

** This position is open to candidates who live in DC, MD, or VA*
* ** This is a field-based position in Washington D.C.*
* ** Expect to spend about 50-75% of your time in the field visiting our members in their homes or in long-term care facilities in the local area.*
* ** You'll need to be flexible, adaptable and, above all, patient in all types of situations.*
* ** Standard

Hours:

Monday-Friday*
* ** 8:00 am-5:00pm**   **(no on-call, no weekends and no holidays required).*
* *
* Primary Responsibilities:

*
* + Assess, plan and implement care management interventions that are individualized for each member and directed toward the most appropriate, least restrictive level of care

+ Conduct timely outreach and in person home visits with members who are newly eligible for EPD Waiver services and complete required assessments in the EMR

+ Identify and initiate referrals for both healthcare and community-based services; including but not limited to financial, psychosocial, community and state supportive services

+ Develop and implement care plan interventions throughout the continuum of care as a single point of contact

+ Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members

+ Advocate for members and families as needed to ensure the member's needs and choices are fully represented and supported by the health care team

+ 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

+ 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 standard)

+ Make outbound calls and receive inbound calls to assess members' current health status

+ Identify gaps or barriers in treatment plans

+ Provide member education to assist with self-management

+ Make referrals to outside sources

+ Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction

+ Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels

This is high volume, customer service environment. You'll need to be efficient,…