Landmark Health, part of the Optum and UnitedHealth Group family of businesses, was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are ill-equipped to navigate our overwhelming healthcare system.
The Nurse Care Manager (NCM), is an integral part of the Interdisciplinary care team (IDT), and is responsible for the overall care management process for high acuity engaged Landmark patients. The NCM has oversight for developing, managing, and coordinating patients’ plan of care to include medical and psychosocial needs and patient-centered goals. The NCM works with patients/caregivers to maintain and improve health status by providing care coordination, health education, guidance and support for medical and psychosocial complex chronic conditions. Professionals in this role elicit input from the IDT based on initial and ongoing comprehensive assessments of the patient.
The NCM uses nursing assessment, evaluation skills, data and reports to guide care planning decisions for the patient. They are skilled at navigating the patients’ health plan benefits to identify providers, resources and vendors that provide required care and services. The NCM works collaboratively with the IDT to provide appropriate, effective, high quality, and cost-effective care to engaged patients in their current residence. If a patient requires care outside their residence, the NCM collaborates with community-based service providers to ensure coordinated care during critical times of transition between health care settings and home.
In addition to the NCM, the Landmark IDT consists of the Regional Medical Director, Pod Leaders, mid-level practitioners, Health Services Director (HSD), clinical supervisors, behavioral health clinicians, social workers, pharmacists, dietitian/nutritionist, ambassadors, care coordinators, the patient and/or caregiver and family.
If you are located within one and a half hour of Grand Rapids, MI, you will have the flexibility to telecommute* as you take on some tough challenges.
- Acts as an advocate for the patient
- Engages and collaborates with patient/caregiver and providers to develop an individualized Care Plan that addresses disease management, health promotion, and patient-centered goals
- Monitors patient progress against Care Plan goals with an emphasis on patient care needs during times of transition in care setting and changes in health status
- In a Delegated Case Management market, understands and adheres to regulatory timeframes and standards required by National Committee for Quality Assurance (NCQA)
- Provides disease management, health promotion and prevention education to patients/caregivers and/or family members to manage disease progression and encourage proper medical testing, so patient can remain as independent as possible
- Completes initial and ongoing patient assessment, using information gathered from patient/caregiver/family, providers, Landmark EMR, and available medical records
- Ability to manage and coordinate care and services within an Interdisciplinary Team
- Manage incoming clinical calls to ensure patients’ medical concerns are addressed by the care team in a timely manner
- Comfortable having and documenting advance directive conversations with patient/caregiver and/or family, and collaborate to reconcile patient/caregiver goals with the current clinical status
- Coordinates care needs across the continuum of care and is the point of contact for patient/caregiver and clinicians
- Leads daily IDT Huddle
- Actively participates in Landmark meetings and education sessions
- Acts as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives
- Facilitates/coordinates admission to a recommended level of care on a temporary or permanent basis
- Promotes patient safety. Reviews or initiates a home safety, functional assessment, and/or falls risk assessment with home-based providers to determine need for adaptive equipment. Assists with acquisition of assistive equipment, as recommended
- Monitors patient during admissions and provides nursing/assisted living facility and provider training on Landmark program philosophy and approach to patient care
- Identifies and reports any potential quality-of-care issues to Clinical Supervisor/HSD, so a plan of improvement can be developed and implemented, as needed
- At times, the NCM may visit a patient in their home for education or assessment, Market/State dependent
- Maintains HIPAA compliance at all times
Reports directly to the Supervisor, Clinical Nurse
- Problem Solving - Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics.
- Customer Service - Manages difficult or emotional customer situations; responds promptly to customer needs; solicits customer feedback to improve service; responds to requests for service and assistance; meets commitments.
- Interpersonal Skills - Focuses on solving conflict; maintains confidentiality; listens to others; keeps emotions under control and overcomes resistance when necessary; remains open to new ideas.
- Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and seeks clarification; responds openly to questions. Must be able to deal with frequent change, delays, or unexpected events.
- Attendance/Punctuality - Is consistently at work and on time; ensures work responsibilities are covered when absent; arrives at meetings and appointments on time.
- Dependability - Follows instructions, responds to management direction; takes responsibility for own actions; keeps commitments; commits to long hours of work when necessary to reach goals; completes tasks on time or notifies appropriate person with an alternate plan.
- Initiative - Volunteers readily; undertakes self-development activities; seeks increased responsibilities; takes independent actions and calculated risks; looks for and takes advantage of opportunities; asks for and offers help when needed; generates suggestions for improving work and workflow.
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.
- Must hold RN License in the State(s) where you will practice. RN License must be current, active, unrestricted and unencumbered
- Proficient in patient-centered Care Plan creation and active management
- 3+ years of clinical practice in a hospital, home care, hospice, clinic, or nursing home setting
- Electronic Medical Record documentation experience
- Computer skills: internet navigation, Microsoft Office – Outlook, Word and Excel
- Advanced interpersonal and telephonic communication skills
- Strong organizational skills
- Ability to complete all work independently and within designated timeframes
- Adaptable, flexible, and able to maintain a positive attitude during change in process, practice or policy
- Access to reliable transportation required; if you are driving a vehicle, you must comply with all the terms of the Landmark Motor Vehicle Safety policy
- Case Management experience
- 1+ years of Utilization Management experience
- Disease state management experience with strong ability to educate patients on health and wellness
- Population Health management experience
- Ability to manage a patient caseload using data and reports
- Regular requirement to sit; use hands to touch, handle or feel.
- Regular requirement to talk and listen.
- Occasional requirement to stand; walk and reach with hands and arms
- Occasional requirement to lift and/or move up to 10 pounds.
- Vision abilities include close vision, peripheral vision, depth perception and ability to adjust focus.
- Ability to travel frequently car
- Initial high frequency visits to patient residences followed by as needed visits during market implementations
- Will require regular travel to patient residences and non-home-based market offices
- Noise level is usually moderate
Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.
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 employer 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.