Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities.
Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.
Optum's Pacific West region is redefining health care with a focus on health equity, affordability, quality, and convenience. From California to Oregon and Washington, we are focused on helping more than 2.5 million patients live healthier lives and helping the health system work better for everyone. At Optum Pacific West, we care. We care for our team members, our patients, and our communities. Join our culture of caring and make a positive and lasting impact on health care for millions.
Position in this function is under the direction of a Registered Nurse, this position is responsible for ensuring the continuity of care in both the inpatient and outpatient settings utilizing the appropriate resources within the parameters of established contracts and patients' health plan benefits. Facilitates a continuum of patient care utilizing basic nursing knowledge, experience, and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs care management functions on-site or telephonically as the need arises.
Reports findings to the Care Management department Supervisor / Manager / Director in a timely manner.
You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Consistently exhibits behavior and communication skills demonstrating Optum's commitment to superior customer service, including quality, care, and concern with every internal and external customer
- Implements current policies and procedures set by the Care Management department
- Conducts on-site or telephonic prospective, concurrent and retrospective review of active patient care, including out-of-area and transplant
- Reviews patients' clinical records of acute inpatient assignment within 24 hours of notification
- Reviews patients' clinical records within 48 hours of SNF admission
- Reviews patient referrals within the specified care management policy timeframe (Type and Timeline Policy)
- Coordinates treatment plans and discharge expectations. Discusses DPA and DNR status with the attending physician when applicable
- Prioritizes patient care needs. Meets with patients, patients' families, and caregivers as needed to discuss care and treatment plan
- Acts as patient care liaison and initiates pre-admission discharge planning by screening for patients who are high-risk, fragile or scheduled for procedures that may require caregiver assistance, placement, or home health follow-up
- Identifies and assists with the follow-up of high-risk patients in acute care settings, skilled nursing facilities, custodial and ambulatory settings. Consults with the physician and other team members to ensure that the care plan is successfully implemented
- Coordinates provisions for discharge from facilities, including follow-up appointments, home health, social services, transportation, etc., to maintain continuity of care
- Communicates authorization or denial of services to appropriate parties. Communication may include patient (or agent), attending/referring physician, facility administration, and Optum claims as necessary
- Attends all assigned Care Management Committee meetings and reports on patient status as defined by the region
- Demonstrates a thorough understanding of the cost consequences resulting from care management decisions through the utilization of appropriate reports such as Health Plan Eligibility and Benefits, Division of Responsibility (DOR), and Bed Days
- Ensures appropriate utilization of medical facilities and services within the parameters of the patient's benefits and/or CMC decisions. This includes appropriate and timely movement of patients through the various levels of care
- Maintains effective communication with the health plans, physicians, hospitals, extended care facilities, patients and families
- Provides accurate information to patients and families regarding health plan benefits, community resources, specialty referrals and other related issues
- Initiates data entry into IS systems of all patients within the parameters of Care Management policies and procedures. Maintains accurate and complete documentation of care rendered,