Onsite Care Coordinator - Geriatric Transitions & Discharge

Optum; Chesterton (IN); Hybrid; USD 71,000 - 127,000; Full time

Benefits offered by this job

Comprehensive benefits

Equity stock purchase

401(k) contribution

Incentive programs

Job summary

Optum Home & Community Care is hiring a Care Coordinator‑Onsite for a hybrid role, supporting patients transitioning from hospital to home in the Chesterton, IN area. The position requires four in‑office days weekly and collaboration with physicians, social workers, and care teams to ensure smooth discharges.

You will perform SNF assessments, review discharge plans, and manage documentation while maintaining PHI confidentiality and meeting CMS guidelines.

Qualifications

• Active, unrestricted clinical license in the state of hire (Registered Nurse, Physical Therapist, Occupational Therapist, or Speech‑Language Pathologist).
• At least 5 years of clinical experience.
• Ability to support specific location(s) for on‑site facility needs within a 30‑mile radius of home location, based on manager discretion.
• Residence within the county listed in the job description.
• Driver’s license and reliable transportation.

Responsibilities

• Serve as the link between patients, families, and appropriate health‑care personnel to ensure smooth, efficient transitions of care.
• Perform SNF assessments on patients using CMS criteria upon admission and periodically throughout the stay.
• Review target outcomes, and discharge plans with providers and families.
• Complete all SNF concurrent reviews, updating authorizations promptly.
• Collaborate with the patient’s health‑care team to establish an optimal discharge plan.
• Assess and monitor patients’ continued appropriateness for SNF settings according to CMS criteria.
• Coordinate peer‑to‑peer reviews with H&C Transitions Medical Directors.
• Enter timely and accurate documentation.
• Review daily census and readmission/quarterly reports to identify improvement opportunities.
• Maintain confidentiality of all PHI in compliance with HIPAA and laws.

Skills

Communication skills

Microsoft Office

Education

Active unrestricted clinical license (RN, PT, OT, or SLP)

Job description

Optum Home & Community Care is hiring a Care Coordinator‑Onsite for a hybrid role, supporting patients transitioning from hospital to home in the Chesterton, IN area. The position requires four in‑office days weekly and collaboration with physicians, social workers, and care teams to ensure smooth discharges.

You will perform SNF assessments, review discharge plans, and manage documentation while maintaining PHI confidentiality and meeting CMS guidelines.