Onsite Care Transitions Specialist

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

Benefits offered by this job

Benefits package

Equity stock purchase

401k contribution

Job summary

Optum Home & Community Care is seeking an onsite Care Coordinator to optimize patients’ recovery journeys within a 30-mile radius of the home location in California. The role involves weekly functional assessments, coordinating discharge plans with an interdisciplinary team, and engaging patients and families to support informed decisions.

Requirements include an active clinical license (RN/PT/OT/SLP), 5+ years of clinical experience, and a valid driver’s license.

Qualifications

• Active, unrestricted clinical license required in state of hire (RN, PT, OT, or SLP).
• Location within 30-mile radius of home location as determined by manager.
• 5+ years of clinical experience.
• Residence near the job's county.
• Driver’s license and reliable transportation.

Responsibilities

• Engage with patients, families, or caregivers weekly and as needed, on-site or telephonically.
• Collaborate with health care teams in interdisciplinary meetings.
• Review discharge goals and coordinate with providers and families.
• Perform SNF assessments using CMS criteria on admission and during stays.
• Assess continued suitability for SNF per CMS criteria.
• Complete SNF stay reviews and update authorizations timely.
• Review referral requests when utilization management is delegated and escalate as needed.
• Cross-train to support multiple contracts/clients.
• Manage assigned caseload efficiently with time management.
• Enter timely and accurate documentation into Coordinate system.
• Adhere to policies and maintain PHI confidentiality under HIPAA.
• Stay current on CMS, Health Plan policies and benefits.
• Attend Care Transitions meetings and promote a positive work environment.
• Perform additional duties as requested.

Skills

Clinical experience

Communication skills

Discharge planning

Care coordination

Time management

Education

Clinical licensure (RN/PT/OT/SLP)

Tools

Microsoft Office (Outlook, Excel, PowerPoint)

Job description

Optum Home & Community Care is seeking an onsite Care Coordinator to optimize patients’ recovery journeys within a 30-mile radius of the home location in California. The role involves weekly functional assessments, coordinating discharge plans with an interdisciplinary team, and engaging patients and families to support informed decisions.

Requirements include an active clinical license (RN/PT/OT/SLP), 5+ years of clinical experience, and a valid driver’s license.