CHOICES Care Coordinator RN – Field Based in Robertson, Dickson, and Cheatham Counties TN

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United Community, 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 CHOICES Care Coordinator (CC) is responsible for facilitating, promoting and advocating for the member’s ongoing self-sufficiency and independence.  The care coordinator will conduct face-to-face and/or telephonic assessments to assess the member’s need for support to alleviate functional deficits.  This supported self care in their activities of daily living allows the member to remain independently functioning in the community.  This allows for the member to age in place, by improving or maintaining the social, emotional, functional and physical health of the member.  

For members who elect residence within a nursing facility, the care coordinator is responsible for educating the member on home and community based alternatives, assessing the member’s potential for and interest in transitioning from nursing facility-to-community.  If a member chooses or it is determined that the member is best served in the facility, the care coordinator is responsible for ongoing assessment and care planning to ensure quality of life services to meet any identified gaps in service.

Additionally, the care coordinator is responsible for sustaining the natural supports of the member.  This includes but is not limited to assessing support caregivers, representative or family members to ensure the ongoing mental and physical health of those natural supports.

99%Intra-Grand Region Travel; climbing steps, lifting computer bag weighing at least 30 pounds.

If you reside in TN, you will have the flexibility to work remotely* as you take on some tough challenges. 

Primary Responsibilities:

• Assessment – The care coordinator will collect in-depth information about a person’s situation and functional ability to identify individual needs, based on functional deficits and risk
• Planning – The care coordinator will assist the member in determining specific objectives, goals and services necessary to obtain the member’s objectives and goals
• Implementation –  The care coordinator will facilitate and execute specific interventions that will lead to accomplish the member’s objectives and goals established in the plan of care to ensure the member’s health, safety, and welfare
• Coordination – The care coordinator will organize, integrate and modify the resources necessary to accomplish the member’s objectives and goals established in the plan of care
• Monitoring – The care coordinator will gather sufficient information for all relevant sources in order to determine the effectiveness of the plan of care
• Evaluation – At appropriate and repeated intervals, the care coordinator will determine the plan of care’s effectiveness in reaching desired outcomes and goals.  This process shall lead to modification or changes in the plan of care to accomplish the member’s objectives and goals

Care Coordination Functions

• Conduct thorough and objective face-to-face assessments of the member 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 change in condition screenings, assessments and/or encounters on HCBS members
• Conduct quarterly telephonic or on-site grand rounds on Nursing Facility (NF) members experiencing changes in condition
• Assess clinical information to develop individual plan of care for members;
• 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
• Utilize criteria for authorizing appropriate home and community based services, obtain authorization for those services and confirm that services are being provided and the member’s needs are being met
• Monitor and ensure that provision of covered physical health, behavioral health, and/or home and community based services are provided as a cost-effective alternative
• Management of critical transitions, such as hospital discharge planning
• 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
• Conduct, review and revises, as necessary, member’s risk assessment and risk agreement
• Maintain appropriate and ongoing communication and collaboration with members, their authorized representations, physicians and health team members and payer representatives
• 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
• Provider members with education about the ability to use advance directives;
• 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

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.

Required Qualifications:

• Registered Nurse with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating the Nurse License Compact Law
• 5+ years health care experience with 3 years clinical experience 
• Proven exceptional skills of critical thinking, follow through, independent self-starter, fully integrated team member, organization, written and verbal communication, computer-literate, problem-solving, professional acumen, human relation skills and analytical skills all 
• Proven ability to work within highly structure contractual time compliance requirements with occasional short turn around times; and
• Demonstrated ability to work effectively in vertically-matrix organizations
• Proven to function independently and responsibly with minimal need for supervision
• Proven to maintain direct and open communication with all levels of the organization
• Demonstrate initiative in achieving individual, team, and organizational goals and objectives
• Proven to organize work and develop strategies for adapting to a constantly changing workload or when confronted with unforeseen situations

Preferred Qualification:

• 3+ years of experience providing care coordination to persons receiving long-term care and/or home and community based services and an additional 2+ years of work experience in managed and/or long-term care settings

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy 

The hourly range for this role is $28.61 to $56.06 per hour based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far- reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.