Onsite Care Transitions Specialist

UnitedHealth Group; San Bernardino (CA); On-site; USD 73,000 - 131,000; Full time

Job summary

Optum Home & Community Care is seeking a Care Coordinator, Onsite, to optimize patients' recovery journeys and coordinate discharge planning for post-acute care. You will work with patients, families, and interdisciplinary teams to ensure timely transitions and CMS-aligned care.

The role requires an active, unrestricted clinical license (RN/PT/OT/SLP), 5+ years of clinical experience, and willingness to travel within a 30-mile radius of the home location. On-site facility focus in California.

Qualifications

• Active, unrestricted clinical license required in state of hire (RN, PT, OT, or SLP).
• Candidate supports specific location(s) within 30-mile radius of home location.
• 5+ years of clinical experience.
• Reside within or near the county listed on the job description.
• Driver's License and access to reliable transportation.

Responsibilities

• Engage with patients, families, or caregivers telephonically or on-site weekly and as needed.
• Collaborate effectively with care teams in interdisciplinary meetings.
• Review target outcomes and discharge plans with providers and families.
• Perform SNF assessments on patients using CMS criteria at admission and periodically.
• Assess and monitor continued appropriateness for SNF per CMS criteria.
• Complete SNF continued stay reviews and update authorizations timely.
• Review referrals when utilization management is delegated and forward to physicians for NOMNC when appropriate.
• Maintain knowledge of multiple contracts/clients to support coverage needs.
• Enter timely and accurate documentation into Coordinate system.
• Adhere to policies, protect PHI per HIPAA, and stay current with CMS and Health Plan policies.
• Attend Care Transitions meetings as requested.

Skills

Communication

Teamwork

Independence

Job description

Optum Home & Community Care is seeking a Care Coordinator, Onsite, to optimize patients' recovery journeys and coordinate discharge planning for post-acute care. You will work with patients, families, and interdisciplinary teams to ensure timely transitions and CMS-aligned care.

The role requires an active, unrestricted clinical license (RN/PT/OT/SLP), 5+ years of clinical experience, and willingness to travel within a 30-mile radius of the home location. On-site facility focus in California.