*Onsite Care Transition Coordinator - SSM DePaul Health Center, Bridgeton, MO
UHG St. Louis, MO
About the Job
To support and coordinate care transitions during a hospital event. Ensure adequate and appropriate care transitions from a hospital setting to the next level of care. Interacting with members, families, care givers and care teams at the bedside. Facilitate care transitions from the hospital to a post-acute inpatient setting to include Skilled Nursing Facility (SNF); Acute Inpatient Rehab (AIR or IRF); Long Term Care hospitals (LTAC); or directly from the hospital to the member’s home or back into a community setting or to the provider practice.
To anticipate, prepare and support hospitals in transitioning UHC members from a hospital event in a way that drives positive experiences for the member and provider; results in efficient and stress-free coordination and ensures the appropriate level of care to meet the clinical needs of the UHC member.
Bridge gaps in discharge coordination and facilitate hard hand offs to post-acute networks and community clinical programs. Ensure smooth internal and external handoffs and partnerships across the enterprise and to support a member-centric approach to care transitions within the local market.
- Work onsite at assigned hospital(s) during business hours Monday - Friday
- Identify any UHC member in an outpatient observation bed or an inpatient medical/surgical setting (excluding maternity members) that may require post-acute care to include either a secondary level of care (SNF, AIR, LTAC) or home health support or services to avoid an unnecessary readmission
- Engage with the hospital care transition or discharge planning teams and the member/family or caregiver to prepare for transitions and assist in facilitating the discharge plan
- Identify and direct care to in-network providers of post-acute services when available to meet the needs of the member
- Request gap exceptions when an in-network provider is not accessible to meet the member’s needs
- Utilize tools, such as Health@Scale, to identify and direct members to in-network providers with experience and quality outcomes specific to the members needs and in the member’s preferred geographic location
- Initiate DME/HME, Infusion or Dialysis, home health, palliative care and hospice providers to support the member’s continued needs after discharge
- Facilitate discharge medications and remove barriers to obtaining quickly, if not prior to discharge within 24 hrs of discharge for follow up within 7 calendar days of discharge
- Review and recommend transportation solutions
- Coordinate clinical information necessary to facilitate medical necessity determinations
- Coordinate P2P with hospital attending physicians and UCS Medical Directors, if necessary to facilitate the most appropriate medical determinations for an AIR or LTAC requests
- Coordinate discharge summary to the next continuum, i.e. AIR, LTAC, SNF, CTP, WPC, Disease Management Programs or an ACO, PCP or Specialist Providers
- Enter timely and accurate discharge date and disposition of member into case management tool
- Notify Clinical Programs such as CTP. TTS, PAT, or House Call practitioners of discharge disposition
- Current unrestricted Licensed Practical Nurse, or Licensed Vocational Nurse license in state of residence OR
- Current LSW in state of residence
- 3+ years clinical experience
- Ability to be credentialed at assigned hospital and meet all hospital occupational health requirements (drug screening, licensure and immunizations)
- Access to reliable transportation and ability to travel to hospital location for primary work site
- Data entry experience into case management systems
- Experience and intermediate skill level working with laptop for daily work (navigating Windows environment)
- Smartphone capabilities
- Case management, community care or resource coordination
- Experience with transitional care services and discharge planning
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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.
Job Keywords: Discharge Planning, Case Management, LPN, LVN, LSW, HTP