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RN, LPN, LVN or LSW - Onsite Care Transition Coordinator (Syracuse)

Position Description

To support and coordinate care transitions during a hospital event.  Ensure adequate and appropriate care transitions from a hospital setting to the next level of care. Interacting with members, families, care givers and care teams at the bedside. Facilitate care transitions from the hospital to a post-acute inpatient setting to include Skilled Nursing Facility (SNF); Acute Inpatient Rehab (AIR or IRF); Long Term Care hospitals (LTAC); or directly from the hospital to the member’s home or back into a community setting or to the provider practice.  To anticipate, prepare and support hospitals in transitioning UHC members from a hospital event in a way that drives positive experiences for the member and provider; results in efficient and stress-free coordination and ensures the appropriate level of care to meet the clinical needs of the UHC member. Bridge gaps in discharge coordination and facilitate hard hand offs to post-acute networks and community clinical programs. Ensure smooth internal and external handoffs and partnerships across the enterprise and to support a member-centric approach to care transitions within the local market.

Position works Onsite at University Hospital Syracuse, NY Primary Responsibilities:Work onsite at assigned hospital(s) during business hours Monday - FridayIdentify any UHC member in an outpatient observation bed or an inpatient medical/surgical setting (excluding maternity members) that may require post-acute care to include either a secondary level of care (SNF, AIR, LTAC) or home health support or services to avoid an unnecessary readmissionEngage with the hospital care transition or discharge planning teams and the member/family or caregiver to prepare for transitions and assist in facilitating the discharge planIdentify and direct care to in-network providers of post-acute services when available to meet the needs of the memberRequest gap exceptions when an in-network provider is not accessible to meet the member’s needsUtilize tools, such as Health@Scale, to identify and direct members to in-network providers with experience and quality outcomes specific to the members needs and in the member’s preferred geographic locationInitiate DME/HME, Infusion or Dialysis, home health, palliative care and hospice providers to support the member’s continued needs after dischargeFacilitate discharge medications and remove barriers to obtaining quickly, if not prior to discharge within 24 hrs of discharge for follow up within 7 calendar days of dischargeReview and recommend transportation solutionsCoordinate clinical information necessary to facilitate medical necessity determinationsCoordinate P2P with hospital attending physicians and UCS Medical Directors, if necessary to facilitate the most appropriate medical determinations for an AIR or LTAC requestsCoordinate discharge summary to the next continuum, i.e. AIR, LTAC, SNF, CTP, WPC, Disease Management Programs or an ACO, PCP or Specialist ProvidersEnter timely and accurate discharge date and disposition of member into case management toolNotify Clinical Programs such as CTP. TTS, PAT, or House Call practitioners of discharge dispositionThis position will require immunization (example: Flu vaccine) and other testing (example: titer)  as mandated by the facility credentialing requirement

Required Qualifications:

Current unrestricted Registered Nurse, Licensed  Practical Nurse, or Licensed Vocational Nurse license in New York  ORCurrent LSW in New York3+ years clinical experienceAbility to be credentialed at assigned hospital and meet all hospital occupational health requirements (drug screening, licensure and immunizations(example: Flu vaccine) and other testing (example: titer)  as mandated by the facility credentialing requirementAccess to reliable transportation and ability to travel to hospital location for primary work siteData entry experience into case management systemsExperience and intermediate skill level working with laptop for daily work (navigating Windows environment) Smartphone capabilitiesExperience with discharge planningMust be able to walk long distances and between facilities and/or buildings

Preferred Qualifications:

Case management, community care or resource coordinationExperience with transitional care services

Careers with UnitedHealthcare. Let's talk about opportunity. Start with a Fortune 6 organization that's serving more than 85 million people already and building the industry's singular reputation for bold ideas and impeccable execution. Now, add your energy, your passion for excellence, your near-obsession with driving change for the better. Get the picture? UnitedHealthcare is serving employers and individuals, states and communities, military families and veterans where ever they're found across the globe. We bring them the resources of an industry leader and a commitment to improve their lives that's second to none. This is no small opportunity. It's where you can 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.

For more information and to apply:

If you have additional questions, please don't hesitate to reach out to Talent Acquisition Manager, Erin McNabb at

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