Onsite Care Transitions Specialist

Optum; Glendora (CA); On-site; USD 48,000 - 87,000; Full time

Job summary

Optum Home & Community Care is seeking an Onsite Care Coordinator to help patients navigate post-acute care journeys and coordinate discharge planning within a 30-mile radius of the home location. This role requires active licenses (RN/PT/OT/SLP) and 5+ years of clinical experience.

The coordinator will engage patients and families, collaborate with care teams, perform SNF assessments, manage documentation, and ensure timely transitions of care while adhering to CMS guidelines and privacy rules.

Qualifications

• Active, unrestricted clinical license required in state of hire.
• 5+ years of clinical experience.
• Candidate will support on-site facility needs within 30-mile radius of home location based on manager discretion.
• Driver's license and access to reliable transportation.

Responsibilities

• Engage with patients, families, or caregivers weekly or on-site to support discharge goals.
• Collaborate with interdisciplinary care teams and participate in meetings.
• Review target outcomes and discharge plans with providers and families.
• Perform SNF assessments and CMS-based reviews.
• Monitor continued appropriateness for SNF settings and update authorizations.
• Review referrals when care transitions are delegated for utilization management.
• Cross-train and maintain knowledge of multiple contracts/clients to support coverage needs across the business.
• Manage assigned caseload efficiently and document accurately in Coordinate.
• Adhere to policies and maintain PHI confidentiality.
• Stay current on CMS guidelines and regulations.

Skills

Registered Nurse license

Physical Therapist license

Occupational Therapist license

Speech Language Pathologist license

Job description

Optum Home & Community Care is seeking an Onsite Care Coordinator to help patients navigate post-acute care journeys and coordinate discharge planning within a 30-mile radius of the home location. This role requires active licenses (RN/PT/OT/SLP) and 5+ years of clinical experience.

The coordinator will engage patients and families, collaborate with care teams, perform SNF assessments, manage documentation, and ensure timely transitions of care while adhering to CMS guidelines and privacy rules.