Optum Home & Community Care, part of the UnitedHealth Group 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 At Home product, together with an interdisciplinary care team 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. We’re connecting care to create a seamless health journey for patients across care settings. Join us to start **Caring. Connecting. Growing together.** The DSNP program combines Optum trained clinicians providing intensive interventions customized to the needs of each individual, in collaboration with the Interdisciplinary Care Team. United providers serve patients’ in their own homes through annual comprehensive assessments, ongoing visits for higher risk members, care coordination during transitions from the hospital or nursing home and ongoing care management. The program’s interdisciplinary care team approach provides needed care in person and through telephonic interventions in collaboration with the members Primary Care Provider and other members of the interdisciplinary care team. **Schedule:** Monday - Friday 8am-5pm Central with potential for 4 x 10 hour days after 6 months of employment. No on call or holiday work. **Territory:** You will be in the field approximately 60% of the time and will work from home when not in the field. Territory is primarily Madison WI- Covers approximately 60-mile radius around clinician’s home. **Primary Responsibilities:** + Assist in coordinating Medicaid/Medicare benefits with a multidisciplinary team approach + Build relationships and work with a variety of populations within the community + Work with populations with complex social and medical needs including adults with serious mental illness and emotional disturbances, members with substance use disorders, and members with other complex or multiple chronic conditions + Assess the members within the scope of licensure and with the frequency established in the model of care. + Establish goals to meet identified health care needs + Plan, implement and evaluate responses to the plan of care + Work collaboratively with a multidisciplinary team to engage resources and strategies to address medical, functional, and social barriers to care + Communicate with the patient’s PCP, specialists, or other health care professionals as appropriate + Assess patient needs for community resources and make appropriate referrals for service + Completely and accurately document in patient’s electronic medical record + Provide members and family members with education regarding health maintenance, disease prevention, condition trajectory and need for follow up as appropriate during each patient visit + Verify and document patient and/or family understanding of condition, plan of care and follow up recommendations + Actively participate in organizational quality initiatives + Participate in collaborative multidisciplinary team meetings to optimize clinical integration, efficiency, and effectiveness of care delivery + Maintain credentials essential for practice, to include licensure, certification (if applicable) and CEUs + Demonstrate a commitment to the mission, core values and goals of UnitedHealth Group and its healthcare delivery including the ability to integrate values of compassion, integrity, performance, innovation and relationships in the care provided to our members 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 + Licensed Masters Social Worker (LMSW) in state of Wisconsin + 2+ years of Social Work experience + Experience working with Electronic Medical records, MS Word, Excel and Outlook + Demonstrated ability to work with diverse care teams in a variety of settings including non-clinical settings (primarily patient homes) + Dedicated work area established that is separated from other living areas and provides information privacy + Access to high-speed internet + Ability to be in field 60% of the time (territory is restricted to only 60-mile radius, other visits are made virtually) + Valid driver’s license + Reliable transportation **Preferred Qualifications:** + Experience with arranging community resources + Experience working in Duals (DSNP) and/or Medicaid environment + Field based work experience + Background in managing populations with complex medical or behavioral needs The salary range for this role is $59,500 to $116,600 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers 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 UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives. _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._ _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._