Transitional Care Nurse Liaison

Requisition Number: 2389121
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale.Join us to start Caring. Connecting. Growing together.
The Transitional Care Nurse is a registered nurse who provides comprehensive education, coaching and support to high-risk patients during transitions from acute care settings. In partnership with Boulder Community Health, this position focuses on readmission prevention through health education, chronic disease self-management, and connecting patients with appropriate care and community resources. By fostering a patient-centered partnership with the care team, the Transitional Care Nurse enhances the patient experience and collaborates to reduce unnecessary high-cost care for those with complex health needs. The Transitional Care Nurse Liaison fosters relationships with area skilled nursing facilities, inpatient rehab hospitals, and other community partners.
Boulder Community Health (BCH) primary care physician clinics are guided by the philosophy of the Patient-Centered Medical Home. The medical home organizes care around patients, while engaging a multidisciplinary care team working proactively to coordinate and track care for each individual patient.
Primary Responsibilities:

• Using department methodology, identify patients for transitional care programs
• Conduct telephonic outreach to patient, family/caregiver, and/or facility to enroll in transitional care program. Conduct initial assessment and medication reconciliation per workflow
• Maintain an active panel of transitional care patients according to department procedures
• While patients are enrolled in transitional care, deliver ongoing care according to the treatment plan. Develop and document patient-centered goals and barriers to care
• Collaborate as a member of a care team with primary and specialty care providers, medical assistants, care managers, nurses, and other clinic staff to provide care to patients based on best practices
• Facilitate communication among care teams to address patient needs and barriers to care
• Provide patient education and community referrals for appropriate and timely care. Initiate and revise patient education resources and tools with BCH partner. Update patient records to reflect current condition, treatment plan, and assess/document patient understanding of treatment plan, medications and adherence to medication regimen
• Participate in regular and ad hoc team, department, company and BCH partner meetings and committees
• Contribute to readmission root cause analyses and quality improvement initiatives
• Maintain working knowledge of health laws, protocols, managed care contracts, and insurance and consider financial impacts to patients
• Perform effectively in stressful and/or emergency situations
• Periodically cross cover for other integrated clinical services staff
• Work is generally self-directed and not prescribed
• Work with less structured, more complex issues
• Identify solutions to non-standard requests and problems
• Solve moderately complex problems and/or conduct moderately complex analyses
• Work with minimal guidance; seeks guidance on only the most complex tasks
• Translate concepts into practice
• Provide explanations and information to others on difficult issues
• Coach, provide feedback, and guide others
• Act as a resource for others with less experience

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:

• Valid and unrestricted RN license (Colorado or compact state license)
• 2+ years as RN in clinical setting
• 2+ years of experience with medication reconciliation
• 2+ years of experience working with an electronic medical record system
• Intermediate level of knowledge and the ability to work independently with Microsoft Office suite: Outlook, Word, Excel, and Teams
• Ability to work Monday - Friday from 8:00am - 4:30pm, Mountain Time Zone
• Reside within a compact state

Preferred Qualifications:

• 2+ years of experience in chronic disease management, case management, discharge planning, utilization management, or adult acute and chronic care management
• Understanding of motivational interviewing techniques or experience with health coaching
• Knowledge of patient-centered care and the Patient-Centered Medical Home (PCMH) model
• Knowledge of quality metrics and shared savings models
• Understanding of Hospital Readmission Reduction Program (HRRP)
• Well-developed oral and written communication skills
• Ability to employ teach-back methods to assess patient understanding
• Reside in the Boulder/Denver area

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location, and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
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