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The Manager, Health Home Care Management is a state licensed RN. The Manager ensures that comprehensive Health Home services are delivered by community based Care Coordinators for the eligible population and are prioritized to meet program contractual outcomes. Health Homes services include comprehensive care management, care transitions, referral management, care coordination, health promotion services, individual, family and caregiver support services, with services connected by health information technology. The Manager, Care Management implements the program through a virtual integrated care coordination platform and works closely with community based Care Coordinators to troubleshoot clinical questions, and ensure that state required program outcomes are met for the population of eligible Health Home enrollees.
Primary responsibilities include:
- Assign newly eligible patients to qualified community based care coordination organizations, and ensure patients are matched to a community based Care Coordinator within 7 days.
- Ensure all patients have an initial assessment completed and initial care plan goals are documented within 30 days of enrollment date.
- Support community based Care Coordination to ensure Health Home eligible patients see their PCP and/or Behavioral Health provider at least every 90 days, or as needed to meet care plan goals. If required by contract, ensure Care Coordinators accompany patients to appointments.
- Coordinate with local hospitals and community agencies to ensure all patients discharged from an emergency visit or inpatient stay have a safe Care Transition to see a clinician for follow up care within 7 days of discharge date.
- Ensure patients receive face to face Individual Support, Family and Caregiver Support as needed to meet priority goals in the patientâ€™s care plan.
- Ensure all required Referrals including referrals to community based services are completed timely and all referral follow ups are completed and tracked to completion
- Monitor results of Care Coordination across the population to ensure gaps in care are being completed.
- Facilitate case conferencing as needed with the entire patient Care Team to ensure that all aspects of the patient plan of care is followed, collaborate with CMO and clinical teams as needed.
- Ensure Care Coordinators meet with patients before scheduled practice visits and medication compliance is reviewed. Help PCP by providing lists of current care alerts, information on medication compliance, updates on referral results and other priority issues.
- Ensure there is structured follow up post visit including follow up with specialists to ensure referrals to specialist appointments are completed and specialist visit documentation is provided to PCP timely and the patient returns for a primary care follow up visit. Proactively track and report referral status.
- Review Population updates daily to identify any unplanned ER visits or Admissions for Health Home patients and ensure safe care transitions for patients to return to primary care within 7 days of discharge date.
- Coordinate support needs for patients using available clinical resources and community based Care Coordinators for education and outreach.
- Collaborate with the entire care team to identify and address barriers to care.
- Collaborate with hospital teams and practice team for transitional needs of high risk patients in medical home practices.
- Use the Accountable Care Population Registry to monitor care for high risk patients, plan visits, track follow up and ensure open care opportunities are addressed.
- Participate in clinical team daily huddles, operations reviews with Accountable Care Consultant/Analyst and monthly JOC meetings with community based organizations, practice and hospital leaders to report progress on high risk patients.
* To become recognized professionally as a Guided Care Nurse, a candidate with a nursing degree and a current license must complete an accredited online Guided Care Nursing course. Upon completion of the course, the nurse is eligible to take an online examination leading to the American Nurses Credentialing Center's new Certificate in Guided Care Nursing. Please note that the ANCC Certificate is not a certification, but rather a one-time recognition of professional achievement.
- Current, unrestricted RN licensed in WA
- Prefer Guided Care Nurse Certification*
- Experience as a Care Coordinator working within a practice as part of the clinical team
- Experience caring for patients with chronic conditions
- Behavioral Health experience
- Strong computer skills
- Ability to lead community based Care Coordinators and caregiver supports
- Prefer Spanish / other second language relevant to Community
UnitedHealthcare Community & State is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.
If you're ready to help make health care work better for more people, you can make a historic impact on the future of health care at UnitedHealthcare Community & State.
We contract with states and other government agencies to provide care for over two million individuals. Working with physicians and other care providers, we ensure that our members obtain the care they need with a coordinated approach.
This enables us to break down barriers, which makes health care easier for our customers to manage. That takes a lot of time. It takes a lot of good ideas. Most of all - it takes an entire team of talent. Individuals with the tenacity and the dedication to make things work better for millions of people all over our country.
You can be a part of this team. You can put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered.
Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
UnitedHealth Group - 18 months ago
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