Job Description

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 and help people live healthier lives while doing your life's best work.(sm)

The primary purpose of this position is to effect efficient transitions for Commonwealth Coordinated Care Plus members across the continuum, including transition of members from the nursing facility care to care in the community, and serve as a clinical resource for the Care Coordination Team. The scope of transition services includes assessing not only medical/health needs but also assessing the Member's social determinants of health (e.g., housing, transportation, social interactions, etc.). and the will development of an inclusive and realistic transition plan for the member and assist in addressing the components of a transition plan, i.e. assist with finding housing; setting up non-medical transportation; helping the individual integrate into the community through clubs, volunteering/work, faith organizations, etc.

**This role requires 40 - 60% local travel and 10 - 15% statewide travel.**

If you are located within Northern VA, you will have the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

* Participate in discharge planning for Members transitioning from acute institutional settings to lower levels of care, including Long Stay Hospitals, Nursing Facilities, and the community
* Coordinate with the assigned care coordinator in discharge planning activities to ensure a safe transition that meets the Member's needs and preferences
* Coordinate with Utilization Management staff, as indicated regarding discharge planning;
* Coordinate with Nursing Facility staff, the Member's assigned care coordinator, and the Member when it is identified that the Member wishes to transition from NF care to the community
* Provide support to care coordinators to maintain Members in the community in lieu of transitioning to institutional settings, as needed
* Utilize and partner with community resources (e.g. CILs, CSBs, AAAs, etc.) and work with staff to facilitate transitions when a member transitions to a lower or less restrictive level of care (e.g., a NF Member wishes to transition to the community, a member in inpatient hospital (medical or psychiatric) transfers to a NF or the community, a CCC Plus Waiver Member no longer meets NF criteria, etc.)
* Provide consistent follow up during the first year after discharge and shall make adjustments to the transition plan to assure acclimation and integration into the community as needed by the Member
* For Dual eligible members enrolled in a DSNP, the Regional Transition Coordinator shall also work with the DSNP care coordinator upon approval of the Member, to coordinate the above activities
* Review daily census and prioritizes daily work in accordance with Care Coordination policies
* Actively collaborate and communicate with physicians and providers to arrange appropriate follow up, discharge planning and/or alternative care and services for plan members
* Coordinate the authorization process for discharge planning needs in accordance with Plan policy and procedure
* Coordinate transition of members to other Level Care Coordinators when indicated
* Perform other delegated duties as assigned

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

* Social Worker with MSW degree or RN with current/unrestricted license in Virginia
* 3+ years of care coordination or behavioral health experience and/or work in a healthcare environment
* 1+ years experience directly working with individuals with complex medical or behavioral needs
* Experience communicating with members who have complex medical needs, the elderly, individuals with physical disabilities, and/or those who may have communication barriers
* Experience communicating and collaborating with multiple stakeholders on the implementation of the transition plan
* Proficient computer skills in Microsoft Office to include Word, Outlook and the ability to type and talk at the same time and toggle between multiple screens
* You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role
* Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained

Preferred Qualifications:

* Experience managing transitions between care setting, including transition from nursing facility care to care in the community
* Experience providing care coordination to persons receiving long-term care and/or home and community based services
* Experience working with Medicaid/Medicare population
* Long term care/geriatric experience
* Case management experience in a clinical setting (hospital, long term care, home health, hospice) or managed care
* Certified Case Manager
* LSW / LCSW

Careers 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)

*All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and 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.

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