Care Coordinator, Onsite - Charleston, SC (Hybrid - RN/PT/OT/ST)

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 member of Care Transitions, we combine the talents of our dedicated staff and leading-edge technology to deliver compassionate care to seniors nationwide. With millions of lives touched, we are innovating the way health care is provided from hospital to home so seniors can lead more fulfilling lives. A career with us means making an impact in the lives of those we serve, including vulnerable populations who benefit from care that is more efficient, more effective and more human. Our environment empowers our team members to elevate our interactions with each other and the experiences we deliver to our patients, giving them more days at home. Join our team, it's your chance to improve the lives of millions as you discover the meaning behind Caring. Connecting. Growing together.

The Onsite Care Coordinator plays an integral role in optimizing patients' recovery journeys. The Care Coordinator completes weekly functional assessments and engages the post-acute care (PAC) inter-disciplinary care team to coordinate discharge planning to support the members PAC journey. The position engages patients and families to share information and facilitate informed decisions. By serving as the link between patients and the appropriate health care personnel, the Care Coordinator is responsible for ensuring efficient, smooth, and prompt transitions of care.

Primary Responsibilities:

• By serving as the link between patients and the appropriate health care personnel, the Care Coordinator is responsible for ensuring efficient, smooth, and prompt transitions of care
• Engage with patients, families, or caregivers either telephonically or on-site weekly and as needed. Collaborate effectively on discharge goals and assist in resolving barriers
• Collaborate effectively with members health care teams with individualized communication and participation in interdisciplinary team meetings
• Review target outcomes and discharge plans with providers and families
• Perform Skilled Nursing Facility (SNF) assessments on patients using clinical skills and utilizing CMS criteria upon admission to SNF and periodically through the patient stays
• Assess and monitor patients' continued appropriateness for SNF setting (as indicated) according to CMS criteria
• Complete all SNF continued stay reviews, updating authorizations on a timely basis
• When Care Transitions is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forwarded to licensed physicians for review and issuance of the NOMNC when appropriate
• Perform other duties and responsibilities as required, assigned, or requested

• Active, unrestricted registered clinical license in state of hire - Registered Nurse, Physical Therapist, Occupational Therapist, or Speech Language Pathologist
• 5+ years of clinical experience
• Support specific location(s) for on-site facility needs within 30-mile maximum radius of home location based on manager discretion
• Reside within or near the county listed in the job description
• Ability to mobilize to and within sites within an assigned local or regional market/area, including car transport, up to 85% of the time
• Driver's license and access to reliable transportation

• Experience working with the geriatric population
• Familiarity with care management, utilization/resource management processes and disease management programs
• Proficient with Microsoft Office applications including Outlook, Excel and PowerPoint
• Patient education background, rehabilitation, and/or home health nursing experience