Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behindCaring. Connecting. Growing together.Responsible for ensuring the transition of care in both the inpatient and outpatient setting utilizing the appropriate resources within the parameters of established contracts and patients’ health plan benefits. Facilitates continuum of patients’ care utilizing advanced nursing knowledge, experience, and skills to ensure appropriate utilization of resources and patient quality outcomes. Performs continuity of care clinic support functions on-site or telephonically per member care delivery needs. Works in conjunction with the PCP and care team in an active leadership role. Ensures evaluation is in alignment with site-based goals.This is a hybrid role that requires some field work/travel up to 3 days per week.Primary Responsibilities:Prioritizes patient care needs upon initial patient/family encounter and addresses emerging issuesMeets with patients, patients’ family, and caregivers to discuss care and treatment per member care delivery needsIdentifies and assists with the patient follow-up in acute care settings, skilled nursing facilities, custodial and ambulatory settingsUses established protocols, pathways, clinical support resources, to optimize clinical outcomesOversees provisions for discharge from facilities including follow-up appointments, home health, social services, transportation, etc., to maintain continuity of careMaintains effective communication with the physicians, hospitalists, care teams, extended care facilities, patients, and familiesDemonstrates a thorough understanding of the cost consequences resulting from care delivery decisions through utilization of reports and systems such as Health Plan Benefits, utilization of metrics and associated care delivery reportsConsults with physician and other team members to ensure that plan of care is successfully implementedMonitors and coaches patients using techniques of motivational interviewing and behavioral change to maximize self-managementWorks in coordination with the care team and demonstrates accountability with patient management and outcomeDiscusses Durable Power of Attorney (DPoA) and advanced directive status with care team when applicableProvides accurate information to patients and families regarding plan benefits, community resources, referrals, and other related issuesDocuments pertinent patient information in applicable electronic platform(s)Ability to work collaboratively with the provider and care team to carry out nursing interventions under proper scope of practiceAbility to provide remote clinic coverage if neededAbility to travel to meet patients and families per care delivery needsPerforms additional duties as assignedYou’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:Associate degree in nursing or LPN with four or more years of experienceNurse with an active and unrestricted license to practice in the state of Florida2+ years applicable clinical experience in a physician’s office, clinical or hospital settingValid Florida driver’s license and proof of insurance. Ability to use own vehicle to meet patients and families per care delivery needsPreferred Qualifications:CCM CertificationComprehensive care continuum management, utilization review or discharge planning experienceHMO experienceKnowledge, Skills, and Abilities:Computer literateKnowledge of HIPAA regulationsKnowledge of current standards of patient careThorough understanding of professional scope of practice. Knowledge and skill in the applications of the techniques and practices of the nursing professionEmbraces and exemplifies core values of Optum and WellMedUnderstands value-based care principles and has proven ability to integrate those principles into own clinical practiceAble to understand, manipulate, and interpret complex data from a variety of reportsAble to evaluate new technology and make recommendations for implementationValue team members and a strong team playerPossesses high ethical standardsAble to make effective and timely decisionsDemonstrated leadership skills and proactively looked for solutions, which produce measurable outcomesAbility to explain medical instructions to patients and their familiesAbility to make sound, independent judgments, and act professionally under pressureAbility to learn and understand appropriate Federal, State, and local regulationsAbility to communicate effectively with patients and all levels of personnel/customers in a professional, courteous, and effective manner using excellent customer service skillsAbility to be a clinical resource for non-licensed office staffAbility to prioritize and multi- task in a high paced environment with good organizational skillsDisplay initiative, accountability, and resourcefulnessAbility to perform care management per industry best practicePay 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 hourly pay for this role will range from $20.00 to $35.72 per hour based on full-time employment. We comply with all minimum wage laws as applicable.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.