Transitional Care Coordinator - Stewart, Montgomery, Rutherford, Smith, Putnam and Surrounding Counties - Full-time / Part-time

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UnitedHealth Group, CHOICES program offers person-centered care planning, service coordination and support services for members receiving long-term care (LTC) and home and community (HCBS) services. The care coordinator is responsible for facilitating, promoting and advocating for the member's ongoing self-sufficiency and independence. Additionally, the care coordinator is responsible for sustaining the natural supports of the member.  This includes but is not limited to assessing the availability of natural supports, representative or family members to ensure the ongoing mental and physical health of those natural supports.  

Transitional Care Coordinator, Stewart, Montgomery, Rutherford, Smith, Putnam and surrounding counties 

Primary Responsibilities:   


Conduct thorough and objective initial and ongoing face-to-face assessments of the member within specific mandated intervals to determine current status and needs, including physical, behavioral, functional, psychosocial and financial and health status expectation 

Conduct monthly telephonic, quarterly face-to-face and other additional assessments as needed to address member change in condition, on HCBS members 

Conduct quarterly telephonic or on-site grand rounds on Nursing Facility (NF) members experiencing changes in condition 

Identify members with the potential for high-risk complications and coordinate the appropriate supported self care in conjunction with the member and care coordination team 

Act as an advocate for an individual's care needs by identifying and communicating opportunities for care interventions, including identifying and addressing functional deficits and gaps in care 

Develops member specific Plan of Care that will be utilized to obtain authorizations for appropriate home and community based services, collaborating with CMA staff to obtain authorization for those services and confirms that services are being provided and the member's needs are being met  

Management of critical transitions, supporting legacy discharge planning staff with member transition to the home setting 

For members transitioning to a setting other than a community-based residential alternative (CBRA) setting, monitor the initiation and daily provision of services in accordance with the member's plan of care and take the immediate action to resolve gaps in care 

Develop and implement targeted strategies to improve health, functional or quality of life outcomes, such as disease management or pharmacy management 

Serve as a point of contact for coordination of all physical health, behavioral health and other home and community based services 

Proactively educate members about the program, including opportunities for consumer direction of HCBS and obtain necessary consents for participation 

Coordinate with the Fiscal Employer Agent (FEA) for consumer direction members, as needed 

Monitor hospitalizations and institutional facility admissions and re-admissions to identify issues and implement strategies to improve outcomes 

Provide assistance in resolving concerns about service delivery or providers 

Coordinate with member's primary care provider, specialists and other providers and care programs to ensure comprehensive, holistic, person-centered approach to care; 

Compare member's plan of care to establish pathways to determine variances and then intervene as indicated 

Routinely assess and monitor member's status, needs and progress; if progress is static or regressive, determine reason and proactively encourage appropriate adjustments to their plan of care, providers and/or services to promote better outcomes 

Report quantifiable impact, quality of care and/or quality of life improvements as measured against the care coordination goals 

Establish and maintain professional working relations with referral sources, community resources and care providers 

Collaborates with the peers on member admissions, transitioning and/or discharge planning 

Required Qualifications:   

RN in the state of Tennessee with an unrestricted license or a Bachelor's Degree in Social Work and a Social Work License in the State of Tennessee
5+ years’ experience working in a Healthcare environment
3+ years of Clinical experience
Previous experience working with Microsoft Office products (Outlook, Word and Excel)
Availability for 75% Travel in the designated counties
Reliable transportation, a valid Driver’s License, and Automobile Insurance
Preferred Qualifications:    

Previous experience providing care coordination to persons receiving long-term care and/or home and community based services
Previous work experience in manager and/or long-term care settings
Working knowledge of Medicare/Medicaid regulations
Case management of Medicaid Waiver populations
Bilingual fluency in English and SpanishCareers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.SM
Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
   
   
Job Keywords: RN, LCSW, Social Worker, Case Manager, Feld Case Manager, VNA, Home Health Nurse, Hospice Nurse, Cookeville, TN, Tennessee