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.
Objective 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.
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
Maintains HIPAA compliance at all times
Reports directly to the Supervisor, Clinical Nurse
Competency: To perform the job successfully, an individual should demonstrate the following competencies:
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.
Required Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Hold RN License in the State(s) where you will practice. RN License must be current, active, unrestricted and unencumbered
3+ years of clinical practice in a hospital, home care, hospice, clinic, or nursing home setting
Electronic Medical Record documentation experience
Proficient in patient-centered Care Plan creation and active management
Computer skills: internet navigation, Microsoft Office - Outlook, Word and Excel
Access to reliable transportation; if you are driving a vehicle, you must comply with all the terms of the Landmark Motor Vehicle Safety policy
1+ years of Utilization Management experience
Case Management experience
Disease state management experience with solid ability to educate patients on health and wellness
Population Health management experience
Ability to manage a patient caseload using data and reports
Advanced interpersonal and telephonic communication skills
Solid 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
Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation.
Physical Demands: Below are the physical requirements which are representative of those that must be met by the employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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
Work Environment: Below is a description of the work environment that the employee will encounter while performing the essential functions of the job.
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
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm)
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.