Escalation Review Nurse RN - D.C, VA, or MD

Optum Home & Community Care, part of the UnitedHealth Group family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere.

As a team member of our Optum At Home product, together with an interdisciplinary care team we help patients navigate the health care system and connect them to key support services. This preventive care can help patients stay well at home.

We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together.

You push yourself to reach higher and go further. Because for you, it's all about ensuring a positive outcome for patients. In this role, you'll work in the field and coordinate the long-term care needs for patients in the local community. And at every turn, you'll have the support of an elite and dynamic team. Join UnitedHealth Group and our family of businesses and you will use your diverse knowledge and experience to make health care work better for our patients.

The United Healthcare at Home program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of members in their place of residence. The DSNP program combines clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, which includes the clinician, the members' Primary Care Provider and other providers, and other professionals.

If you are located in the District of Columbia, you will have the flexibility to work remotely* as you take on some tough challenges.

This role is a telephonic role with expectation of at least quarterly in person staff meetings.

You'll need to be flexible, adaptable and, above all, patient in all types of situations.

Core Position Hours: Monday - Friday, 8:00am - 5:00pm

Primary Responsibilities:

• Assess, plan and implement care management interventions that are individualized for each patient and directed toward the most appropriate, least restrictive level of care
• Assist and address member escalations coming from DHCF officials, hospital systems, DC agencies, members, families, caregivers or others.
• Address and triage Care Management and Utilization Management issues in partnership with the member's assigned Care Manager and Market Leadership
• Identify and initiate referrals for both healthcare and community-based services; including but not limited to financial, psychosocial, community and state supportive services
• Develop and implement care plan interventions throughout the continuum of care as a single point of contact
• Communicate with all stakeholders the required health-related information to ensure quality coordinated care and services are provided expeditiously to all members
• Advocate for patients and families as needed to ensure the patient's needs and choices are fully represented and supported by the health care team
• Identify appropriate interventions and resources to meet gaps (e.g., psychosocial, transportation, long-term care) based on specific consumer needs from both the health care and psychosocial / socioeconomic dimensions of care
• Document the plan of care in appropriate EHR systems and enter data per specified
• Maintain consumer engagement by establishing rapport, demonstrating empathy, and building a trusting relationship
• Collaborate with primary providers or multidisciplinary team to align or integrate goals to plan of care and drive consistent coordination of care
• Provide ongoing support for advanced care planning.
• Reassess plan of care at appropriate intervals based on initial objectives, significant change of condition, or achievement of goals
• Understand and operate effectively/efficiently within legal/regulatory requirements
• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standard)
• Make outbound calls and receive inbound calls to assess members' current health status
• Identify gaps or barriers in treatment plans
• Provide patient education to assist with self-management
• Make referrals to outside sources
• Provide a complete continuum of quality care through close communication with members via in-person or on-phone interaction
• Support members with condition education, medication reviews and connections to resources such as Home Health Aides or Meals on Wheels

This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. Strong computer and software navigation skills are critical. You should also be strongly patient-focused and adaptable to changes.

What are the reasons to consider working for UnitedHealth Group? Put it all together - competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
• More information can be downloaded at: http://uhg.hr/uhgbenefits

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:

• Active, unrestricted Registered Nurse (RN) license
• 1+ years of experience working within the community health setting in a health care facility
• 1+ years of experience providing community-based care management to members receiving long-term care, personal care services, private duty nursing, or home health
• Demonstrated competency working with Enrollees and/or families who require intensive case management services
• Driver's license and access to reliable transportation

Preferred Qualifications:

• Certified Case Manager (CCM) certification
• Resident of the District of Columbia strongly preferred; consideration will be given to those outside of the District of Columbia within commutable distance
• Experience in managing populations with complex medical or behavioral needs
• Experience working with Home Care Based Services and/or patients in community and home-based settings
• Experience with case management, utilization review, discharge planning, concurrent review and/or risk management
• Prior field-based work experience

Additional Considerations:

• Knowledge of and experience with D.C. community organizations that offer resources that meet the needs of Enrollees and their families
• Knowledge of and experience with Medicaid LTSS and behavioral health services and service systems
• Ability to travel in assigned region to visit Dual Special Needs Plan members in their homes and/or other settings, including community centers, hospitals or providers' offices
• Solid computer skills including EHR documentation, MS Office, etc.
• 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

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits re subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

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.