RN Field Clinical Care Coordinator - Plymouth County, MA

About the role

The RN Clinical Care Coordinator will be the primary care manager for a panel of members with complex medical and behavioral needs, coordinating care to address medical, behavioral, and socioeconomic factors and promote appropriate service utilization and improved quality of care.

Responsibilities

• Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs
• Develop and implement person‑centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence‑based guidelines
• Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan
• Provide education and coaching to support member self‑management of care needs and lifestyle changes to promote health
• Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission
• 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

Required Qualifications

• High School Diploma/GED
• Current and unrestricted independent licensure as a Registered Nurse for MA
• 2+ years of clinical experience
• Intermediate level of proficiency with MS Office, including Word, Excel and Outlook
• Access to a designated quiet workspace in your home (separated from non‑workspace areas) with the ability to secure Protected Health Information (PHI)
• Reside in a location that can receive a UnitedHealth Group approved high‑speed internet connection or leverage an existing high‑speed internet service
• Ability to travel within assigned territory to meet with members and providers
• Access to reliable transportation and valid US driver's license