Care Transitions Navigator (RN/OT/PT/SLP)

Optum; Ontario (CA); Hybrid; USD 48,000 - 87,000; Full time

Job summary

Optum Home & Community Care is seeking a skilled care transition professional to work with patients, families, and care teams to navigate discharge planning and SNF assessments. The role emphasizes CMS criteria, documentation, and cross-functional collaboration to ensure safe transitions.

Candidates should have an active clinical license (RN/PT/OT/SLP) and at least 5 years of clinical experience, with willingness to travel within a 30-mile radius as needed.

Qualifications

• Active, unrestricted clinical license in the state of hire (RN, PT, OT, or SLP).
• Residence within the specified county or nearby as listed in the job description.
• 5+ years of clinical experience.
• Driver's license and reliable transportation.

Responsibilities

• Engage with patients, families or caregivers telephonically or on-site weekly.
• Collaborate with care teams and participate in interdisciplinary meetings.
• Review discharge plans with providers and families.
• Perform SNF assessments using CMS criteria on admission and during stays.
• Monitor ongoing appropriateness for SNF per CMS criteria.
• Complete SNF continued stay reviews and update authorizations promptly.
• Review referrals for continued stay when delegated for utilization management.
• Cross-train to support coverage across contracts/clients.

Skills

Care coordination

Communication skills

Documentation accuracy

Time management

Education

Active, unrestricted RN/PT/OT/SLP license

Tools

Coordinate platform

Job description

Optum Home & Community Care is seeking a skilled care transition professional to work with patients, families, and care teams to navigate discharge planning and SNF assessments. The role emphasizes CMS criteria, documentation, and cross-functional collaboration to ensure safe transitions.

Candidates should have an active clinical license (RN/PT/OT/SLP) and at least 5 years of clinical experience, with willingness to travel within a 30-mile radius as needed.