Registered Nurse Field Case Manager -DC, MD, VA

$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.

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.

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

• Current unrestricted Registered Nurse license in Washington DC or willing to obtain within 90 days of hire
• Certified in Basic Life Support
• 2+ years of experience working with MS Word, Excel and Outlook
• 1+ years of experience in post - acute care, such as long-term care
• 1+ years of clinical case management experience
• 1+ years of experience with using an Electronic Medical Record
• Valid Driver's License and access to reliable transportation
• Ability to work in a field-based capacity in Washington, D.C.
• Reside within 50 miles of Washington, DC

• Certified Case Management (CCM)
• 1+ years of experience working with the geriatric population
• 1+ years of LTSS (Long Term Services and Supports)
• 1+ years of HCBS (Home and Community Based Services) experience
• Field based experience going into members' homes
• Experience creating care plans
• Case Management experience
• Background in managing populations with complex medical or behavioral needs