Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that's improving the lives of millions. Here, innovation isn't about another gadget, it's about making health care data available wherever and whenever people need it, safely and reliably. There's no room for error. Join us and start doing your life's best work.(sm)

naviHealth, part of Optum and the UnitedHealth Group family of businesses, combines 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 delivered 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.

The Transitional Care Coordinator (TCC) plays an integral role in patient journeys towards better well-being by serving as the communication link between the patient and their interdisciplinary health care team. The Transitional Care Coordinator is responsible for identifying the appropriate post-acute care (PAC) setting and evaluating a defined population for transitional needs post-discharge to improve outcomes. This ensures that efficient, smooth, and prompt health care services will be delivered to the patient across the continuum of care, beyond a single episode of care and addresses the ongoing needs of the patient. The TCC engages the hospital care team, the physicians, post-acute care providers in the home or home-like setting, the patient and their families/caregivers while providing objective information and support throughout the care continuum focusing on the safe transition of care.

The TCC role is located in Lakewood, CA, primarily based onsite (hospital/office setting) and work from home 2 - 3x per week.

Primary Responsibilities:

• Perform functional assessments on a defined population of patients using clinical skills and proprietary PAC management workflow system and functionally based assessment technology tools. Provide outcome targets to the appropriate audience
• Utilize naviHealth proprietary technology and industry-standard evidence-based tools for consideration of the appropriate level of care, readmission risk, and needed interventions
• Maintain nH Coordinate case documentation per established standards
• Collaborate effectively with patients’ interdisciplinary health care teams to coordinate an optimal transition plan to the most appropriate PAC setting. The health care team includes physicians, health plan UM/CM Nurse, hospital discharge planners, referral coordinators, etc. The patient and caregiver are naviHealth.com © 2020 naviHealth, Inc. All Rights Reserved. involved in the decision-making process to minimize service fragmentation during care transition
• Provide telephonic post-discharge support to assist the defined population of patients in meeting short and long-term goals with regards to their overall wellbeing. The TCC may collaborate with other care team members such as home health providers to avoid redundant telephonic follow up and coordinate care
• Partner with acute and post-acute interdisciplinary care team members to support discharge planning, resolve barriers, and connect the patient to community resources and additional services
• Assess and monitor patients’ appropriateness for care setting (as indicated) according to nH Predict™, InterQual criteria and/or industry standard evidence based criteria. Communicate with hospital case management and physicians on identified patients that do not meet criteria and assist with developing appropriate discharge setting as needed
• Utilize knowledge of behavioral change science and principles to guide patient/caregiver interventions
• Address end of life issues including hospice and palliative care options
• Practice cultural competency with awareness and respect for diversity
• Facilitate the development of a culturally sensitive individualized transitional care plan for services that including clinical, psycho-social, and environmental needs. Monitors and evaluates the effectiveness of the plan. Make recommendations for changes in the transitional care plan that incorporates transitional needs, as indicated
• Provide individualized evidence-based condition-specific patient education directed at self-care and reduction of exacerbations. Education is delivered at the appropriate health literacy level in a culturally sensitive manner
• Coordinate comprehensive post-discharge health care services, support programs, and referrals for community-based services
• Review readmission reports, quarterly and other reports as needed to assist with the identification of opportunities for process improvement
• Maintain confidentiality of all PHI information in compliance with HIPPA, federal and state regulations, and laws

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Qualifications - External

Required Qualifications:

• Active, unrestricted Registered Nurse licensure
• 3+ years of clinical experience
• Demonstrated exceptional verbal and written interpersonal and communication skills
• Proven solid problem solving, conflict resolution, and negotiating skills
• Proficient with Microsoft Office applications including Word, Excel and PowerPoint
• Independent problem identification/resolution and decision-making skills
• Demonstrated ability to prioritize, plan, and handle multiple tasks/demands simultaneously
• Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Medical specialties:

• Geriatrics

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• Hybrid remote

Ability to commute/relocate:

• Lakewood, CA 90712: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Nursing: 1 year (Preferred)
• Case management: 1 year (Preferred)

License/Certification:

• RN (Preferred)

Willingness to travel:

• 25% (Preferred)

Work Location: Hybrid remote in Lakewood, CA 90712

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