Social Worker Field Care Coordinator - Care at Home - DC, MD, VA

$5,000 Sign-on Bonus for External Candidates Optum Home & Community Care, part of the Optum family of businesses, is creating something new in health care. We are uniting industry-leading solutions to build an integrated care model that holistically addresses an individual's physical, mental and social needs - helping patients access and navigate care anytime and anywhere. As a team member of our Optum Care at Home team, together in an interdisciplinary care environment, we help patients navigate the health care system and connect them to key support services. This preventive care can help patients stay well at home. This life-changing work adds a layer of support to improve access to care. We're connecting care to create a seamless health journey for patients across care settings. Join us to start Caring. Connecting. Growing together. The Optum Care at Home program is a longitudinal, integrated care delivery program that coordinates the delivery and provision of clinical care of members in their place of residence. The DSNP program combines clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team, which includes the clinician, the member's Primary Care Provider and other providers, and other professionals. This position is open to candidates who live in DC, MD, or VA This is a field-based position in the greater Washington D.C. area, expect to spend about 50-75% of your time in the field visiting our members in their homes or in long-term care facilities in the local area. You’ll need to be flexible, adaptable and, above all, patient in all types of situations. Standard Hours: Monday - Friday normal daytime business hours (no on‑call, no weekends and no holidays required). Primary Responsibilities: Assess, plan and implement care management interventions that are individualized for each member and directed toward the most appropriate, least restrictive level of care Develop and implement care plan interventions throughout the continuum of care as a single point of contact Communicate with all stakeholders the required health‑related information to ensure quality coordinated care and services are provided expeditiously to all members Advocate for members and families as needed to ensure the member’s needs and choices are fully represented and supported by the health care team Identify appropriate interventions and resources to meet gaps (e.g., psychosocial, transportation, long-term care) based on specific consumer needs from both the health care and psychosocial / socioeconomic dimensions of care Document the plan of care in appropriate EHR systems and enter data per specified Maintain consumer engagement by establishing rapport, demonstrating empathy, and building a trusting relationship Collaborate with primary providers or multidisciplinary team to align or integrate goals to plan of care and drive consistent coordination of care Provide ongoing support for advanced care planning Reassess plan of care at appropriate intervals based on initial objectives, significant change of condition, or achievement of goals Understand and operate effectively/efficiently within legal/regulatory requirements Utilize evidence‑based guidelines (e.g., medical necessity guidelines, practice standard) Make outbound calls and receive inbound calls to assess members’ current health status Identify gaps or barriers in treatment plans Provide member education to assist with self‑management Make referrals to outside sources Provide a complete continuum of quality care through close communication with members via in‑person or on‑phone interaction Support members with condition education, and connections to resources such as Home Health Aides or Meals on Wheels 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: Master’s degree in social work or another related clinical field Active and unrestricted LICSW or LGSW license in Washington D.C. or ability to obtain Washington, D.C. License within 90 days of hire 2+ years of experience in long-term care, home health, hospice, public health or assisted living 2+ years of experience working with MS Word, Excel and Outlook 1+ years of experience with using an Electronic Medical Record 1+ years of clinical case management experience Valid Driver’s License and access to reliable transportation Ability to work in a field‑based capacity in Washington, D.C. Reside within 50 miles of Washington, D.C Preferred Qualifications: Certified Case Management (CCM) 1+ years of experience working with geriatric population 1+ years of LTSS (Long Term Services and Supports) Experience with arranging community resources Field‑based work experience going into member homes HCBS (Home and Community Based Services) experience Background in managing populations with complex medical or behavioral needs Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, 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. a comprehensive benefits package incentive and recognition programs equity stock purchase 401k contribution (all benefits are subject to eligibility requirements) 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. #J-18808-Ljbffr UnitedHealth Group