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 diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
Positions in this family require a current, unrestricted RN license in the applicable state, as indicated in the function description and/or job title.
Positions in this function require various nurse licensure and certification based on role and grade level. Licensure includes RN depending on grade level, with current unrestricted licensure in applicable state. These roles identify, coordinate, or provide appropriate levels of care under the direct supervision of an RN or MD. Function is responsible for clinical operations and medical management activities across the continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating). This includes case management, coordination of care, and medical management consulting. Function may also be responsible for providing health education, coaching and treatment decision support for members. Includes Health Coach, Health Educator, and Health Advocate roles that require an RN.
General Job Profile:
- Reviews the work of others
- Develops innovative approaches
- Sought out as expert
- Serves as a leader/ mentor
Primary Responsibilities:
- Anticipates customer needs and proactively develops solutions to meet them
- Serves as a key resource on complex and/or critical issues
- Solves complex problems and develops innovative solutions
- Performs complex conceptual analyses
- Reviews work performed by others and provides recommendations for improvement
- Forecasts and plans resource requirements
- Authorizes deviations from standards
- May lead functional or segment teams or projects
- Provides explanations and information to others on the most complex issues
- Motivates and inspires other team members
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- Undergraduate degree or equivalent experience
- Current unrestricted RN licensure in applicable state
Functional Competency & Description
- CMT_Conduct Comprehensive, Holistic, or Focused Assessment of Consumer's Health Care
- Scope of practice impact:The LPN:can contribute to the assessment of health status through gathering and recording of assessment data, observing and monitoring and reporting of changes in condition to the supervising RN.The RN is accountable for integration of the assessment for the plan
- Perform initial review of consumer health records and current health status (e.g., health risk scores) to identify health risk and determine next steps
- Receive information from consumers about specific symptoms and questions
- Conduct interviews to understand cause and effect, gather or review health history for clinical symptoms, and determine health literacy
- Ask open ended questions, identify significant from insignificant responses, ask about other diagnoses, probe for additional information, and redirect as necessary
- Evaluate consumer data throughout the assessment process to identify inconsistencies and adherence to Evidence Based Guidelines - RN
- Identify and prioritize gaps to develop plan of care to empower consumers to meet identified goals- RN
- Determine consumer's willingness to engage in plan of care and readiness for change -RN
- Document assessment information and enter data in appropriate system
- CMT_Perform Planning Activities Based on Health Care Assessment
- Scope of Practice impact:The LPN contributes to the development and modification of the plan of care.The RN identified the needs and goals, determines, modifies and prioritizes strategies to support the consumer is achieving the goals and expectations
- Consult with others (e.g., interdisciplinary team members) to review clinical assessment and obtain input as necessary
- Engage translators as appropriate
- Identify appropriate interventions and resources to meet gaps (e.g., psychosocial, transportation, long-term care) based on specific consumer needs
- Review and identify appropriate evidence based information for consumers
- Consult with consumer regarding possible areas for intervention and priorities
- Determine short and long term health goals
- Evaluate the consumer's understanding of health gaps and potential interventions
- Discuss benefits and risks of potential interventions with consumer to assess their willingness to change and support the plan of care
- Take member support and priorities into account to identify initial plan of care
- Document the plan of care in appropriate systems and enter data per specified format
- CMT_Implement Interventions to Achieve GoalsD)Advanced
- Scope of Practice Implications:LPN contributes to the implementation process under the direction of the RN
- Refer consumers to appropriate internal and external resources as needed
- Engage consumer with meaningful interaction that will motivate commitment and increase level of activation
- Identify possible challenges to consumer success and provide continued support for goal attainment
- Contact member or provider to gather information on consumer progress toward plan goals
- Identify opportunities to update the care plan based on preferences, knowledge, success, progress
- Maintain consumer engagement by establishing rapport, demonstrating empathy, and building a trusting relationship
- Communicate rationale for interventions that are tailored to each situation to best teach and motivate consumers
- Partner with primary providers or multidisciplinary team to align or integrate goals to plan of care
- Determine consumer's level of health literacy and adjust approach or explanations to meet consumer needs
- Provide approved health information resources to consumers in a secure fashion (e.g., web links, e-mails)
- Document information using appropriate grammar, spelling, and punctuation, and ensure all critical information is included per documentation guidelines
- CMT_Evaluate Effectiveness of InterventionsD)Advanced
- Scope of practice implications:The LPN can contribute to the evaluation of the plan of care by gathering, observing,
- communicating consumers responses to interventions.Any modification in plan of care would be in collaboration with the RN
- Reassess plan of care at appropriate intervals based on initial objectives, significant change of condition, or achievement of goals
- Conduct follow up calls as indicated to reevaluate plan of care
- Determine whether consumer can demonstrate goal attainment
- Evaluate effectiveness of specific interventions to determine whether desired outcomes are achieved
- Revise plans of care or close cases based on consumer success toward goals
- Document goal attainment (e.g., proof points, completion of intervention to obtain goal, caller understanding of action plan) and enter data in appropriate systems
- CMT_Demonstrate Business and Industry KnowledgeD)Advanced
- Demonstrate knowledge of computer functionality and software applications (e.g., navigating systems, troubleshooting, electronic charting, accessing intranet and record management databases)
- Demonstrate knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, commercial) or regulatory bodies (e.g., HIPAA, URAC, ISO, Milliman, NCQA)
- Demonstrate understanding of relevant health care benefit plans (e.g., conservation of benefits)
- Demonstrate knowledge of applicable area of clinical specialization
- Utilize resources to enhance professional practice and development based on learning gaps or new information
- CMT_Drive Effective Clinical Decisions within a Business EnvironmentD)Advanced
- Demonstrate understanding of business implications of clinical decisions
- Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed
- Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
- Identify and implement innovative approaches to the practice, in order to achieve or enhance quality outcomes and financial performance
- Use appropriate business metrics (e.g. member/FTE, length of stay, readmission rates, STAR ratings, member engagement rates) and applicable processes/tools (e.g. cost benefit analysis, return on investment, performance, staffing calculator) to optimize decisions and clinical outcomes
- Prioritize work based on business algorithms and established work processes, or in their absence, identify business priorities and build consensus to triage and deliver work (e.g. assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up.)
- Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, ARRA, SOX, CHAP, accreditation, state.)
New York Residents Only: The salary range for this role is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.
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.
Diversity creates a healthier atmosphere: Unitedhealth Group is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
Unitedhealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
