Field Nurse Case Manager

Optum Home & Community Care, part of the UnitedHealth Group 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 At Home product, together with an interdisciplinary care team 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.

We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

Registered Nurses in the Optum 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 Field Case Manager RN may perform care and counsel of the ill, injured, or infirm, in the promotion and maintenance of health with individuals, groups, or both throughout the life span. They help to manage health problems and coordinate health care for the Optum 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.

Primary Responsibilities:

• Reports to RN Manager
• Assess the health status of members as 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 the multidisciplinary 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
• 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
• Completely 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 multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery
• Maintain credentials essential for practice, to include licensure, certification (if applicable) and CEUs
• Demonstrate a commitment to the mission, core values and goals of UnitedHealthcare and its healthcare delivery including the ability to integrate values of compassion, integrity, performance, innovation and relationships in the care provided to our member

• Current unrestricted licensure as RN in Ohio
• 2+ years of relevant experience
• Experience in assessing the medical needs of patients with complex behavioral, social and/or functional needs
• Demonstrated ability to work with diverse care teams in a variety of settings including non-clinical settings (primarily patient homes)
• Proven solid computer skills, including use of electronic medical records
• Ability to travel 100% of the time in the Cuyahoga County, OH area for field-based work within 60 miles of residence
• Valid driver's license
• Access to reliable transportation that will enable you to travel to client and/or patient sites within a designated area

• Field based experience
• Case management experience
• Proven effective time management and communication skills