Medical Home Care Advocate, Yuma AZ

Medical Home Care Advocate, Yuma AZ

Title: Medical Home Care Advocate, Yuma AZ
Location: US-AZ-Yuma

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The Medical Home Care Advocate supports assigned practices with on site care coordination to
facilitate appropriate primary care visit planning, follow up and coordination to reduce adverse events
for high risk/ Health Home cohort patients. The Care Advocate coordinates with practice clinical
teams and United teams/resources to ensure high risk patients receive optimal care at each visit.

Primary responsibilities include:
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Work on site with assigned Medical Home practice clinical team supporting the clinical team in managing cohorts of high risk/health home members to ensure they are seen by their PCP as needed and meet goals.
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Work with the PCP to ensure that all aspects of the patient plan of care is followed.
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Plan for each PCP visit, prep the PCP, meet with cohort patients before scheduled practice visits and complete medication reconciliation. Prep PCP by providing lists of current care opportunities, information on medication compliance, updates on referral results and other priority issues.
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Follow up with specialists to ensure referrals to specialist appointments are completed and specialist visit documentation is provided to PCP timely and the patient returns for a primary care follow up visit. Proactively track and report referral status.
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Review Medical Home Registry updates daily to identify any unplanned ER visits or Admissions for High Risk Cohort patients and coordinate to return patient to primary care within 7 days.
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Coordinate support for patients using available United care management ICCT resources and local Promotoras for education and outreach.
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Collaborate with the practice Medical Home clinical team to identify and address barriers to closing current care opportunities.
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Collaborate with local hospital UM nurse and transition nurse for transitional needs of high risk patients in medical home practices.
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Use the Medical Home Population Registry for High Risk patients to plan visits, track follow up and ensure open care opportunities are addressed.
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Report daily, weekly and monthly measurable progress on high risk patients to clinical teams and at JOC.


What makes your clinical career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You can work with in an incredible team culture; a clinical and business collaboration that is learning and evolving every day. And, when you contribute, you'll open doors for yourself that simply do not exist in any other organization, anywhere.


This is a key role in our Medical Home implementation with FQHCs, with the nurse directly 'embedded' in the Medical Home practice in support of the PCP and the clinical team in line with the Johns Hopkins Guided Care model. The nurse will support the Practice clinical teams/PCPs in care coordination of high risk complex patients: proactively working with the practice and the population registry to ensure (a) patient visits are timely, planned and effective, (b) the visit is optimized with all planned care completed, (c) follow up referral management is tracked and completed. The nurse must have the maturity and experience to interact with Practice clinical leadership with confidence. Works collaboratively with ICM nurses in hospital to ensure effective care transitions for all members discharged back to the practice/s. Nurse will cover up to five medical home practices in Yuma Community.


AmeriChoice is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.

If you're ready to help make health care work better for more people, you can make a historic impact on the future of health care at AmeriChoice.
Basic Qualifications:

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Licensed RN in State of AZ
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3 plus years clinic or RN leadership experience
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experience working within a practice setting as part of a team
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experience caring for patients with chronic conditions
Preferred qualifications:

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Prefer Guided Care Nurse Certification*


and a current license must complete an accredited online Guided Care Nursing course. Upon
completion of the course, the nurse is eligible to take an online examination leading to the American
Nurses Credentialing Center's new Certificate in Guided Care ase note that the ANCC
Certificate is not a certification, but rather a one-time recognition of professional achievement.



UnitedHealthcare Community & State is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.

If you're ready to help make health care work better for more people, you can make a historic impact on the future of health care at UnitedHealthcare Community & State.

We contract with states and other government agencies to provide care for over two million individuals. Working with physicians and other care providers, we ensure that our members obtain the care they need with a coordinated approach.



This enables us to break down barriers, which makes health care easier for our customers to manage. That takes a lot of time. It takes a lot of good ideas. Most of all - it takes an entire team of talent. Individuals with the tenacity and the dedication to make things work better for millions of people all over our country.

You can be a part of this team. You can put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered.

Diversity creates a healthier atmosphere: equal opportunity employer M/F/D/V

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing.



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