Nurse Case Manager - Transition of Care

About the role

Optum, part of UnitedHealth Group, is looking for a Registered Nurse to join its Optum Care Delivery team in Utah. The Transition of Care (TOC) RN is telephonic and coordinates and manages care for members moving from observation, inpatient, skilled nursing and other post-acute settings. The role works with patients, caregivers, providers, Community Health Workers and interdisciplinary teams to support safe transitions, reduce avoidable readmissions and emergency department use, and improve health outcomes. Utah residents can work remotely.

Key responsibilities

• Assess, develop, implement and monitor individualized care plans for discharged acute care patients and high-risk Medicare Advantage patients
• Manage a caseload and conduct clinical assessments of medical, functional, psychosocial and environmental factors affecting recovery
• Reach out to eligible patients after hospitalization, ED visits or post-acute stays and evaluate discharge plans
• Perform medication reconciliation and coordinate care across providers, hospitals, skilled nursing facilities, home health agencies and community resources
• Engage patients and caregivers, facilitate follow-up appointments and monitor progress during the transition
• Identify patients at risk of readmission or ED use and intervene; document accurately and follow HIPAA and quality standards
• Take part in performance improvement, care coordination and population health initiatives

Required profile

• Active, unrestricted Utah RN license
• 3+ years of clinical nursing experience, preferably in acute care, care management, discharge planning or transitional care
• Experience in managed care, Medicare Advantage, value-based care, care management or population health
• Preferred: BSN, case management certification (CCM, ACM-RN or equivalent), and experience in readmission prevention or post-acute care
• Valid, unrestricted driver's license, reliable transportation and current auto insurance

Required skills

• Proficiency with electronic medical records, case management systems and Microsoft Office
• Clinical assessment, critical thinking and communication skills

What we offer

• Salary of $72,800 - $130,000 annually for full-time employment
• Comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (subject to eligibility)