What are the responsibilities and job description for the Field RN - Chronic Risk / AT Home Care Program position at Reuben Cooley?
Job Description
IDEAL CANDIDATE:
Willing to travel inside Philadelphia area
Perform home visits with patients enrolled in At Home Care Chronic Risk Program and/or Advanced Care program (ACP)
Provides up-to-date health care advice/education regarding health promotion, illness prevention, and management of disease utilizing nursing assessment data, patient, family, and approved At Home Care Triage protocol. Considers the physical, cultural, psychosocial, spiritual, age-specific and educational needs of the patient.
Systematically assesses patients' actual or potential health care needs, prioritizes their urgency and uses creative and effective problem solving/decision making while recommending an appropriate disposition per clinician and protocol direction.
Documents nursing assessment, planning, implementation in the electronic health record. Documentation is timely and in accordance with policy. Evaluates the patients' and family's response to teaching. Documentation includes presenting problem, nursing assessment interventions, education and patients' response to interventions/treatments and education.
Makes follow-up telephone calls to patients and referrals as appropriate.
Provide telephonic nursing assessment and triage supported by triage protocols. This includes, timely and accurate triage documentation, escalation, and follow up
Initiate medication changes and other orders, as directed by provider in response to a triage call.
Health Literacy Improvement
Improves Health literacy and coaches consumers on chronic conditions including disease process and trajectory, medication education including possible side effects, plan of care, and individualized care goals management in a culturally sensitive and acceptable manner for the patient or caregiver.
Identifies problems or gaps in care, and offers opportunity for intervention
Coordinates services and referrals to health programs, and participates in patient education and outreach tied to HEDIS initiatives
Works to improve access to care, and works as part of the team to manage heath care cost and utilization
Provider Support
Completes telephonic nursing assessments including social determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider
Assists with organizing and running a chronic care and/or interdisciplinary care team rounds where high risk patients and care plans are identified
Participate using a team approach to create a care plan for the patient
Maintain and update spreadsheets and documents provided by health plan to prep weekly rounds of documentation
Post-Acute Management and Coordination
Participation in weekly care coordination with health plan case management as directed by market needs
Referral Management Care Coordination and tracking of hospice consults within 24 hrs. of order placement
Qualifications
Requirements:
Active, unrestricted RN license in Pennsylvania
Ability to obtain compact license and/or additional state licensure as needed
3 or more years of experience as a Registered Nurse
Proficient level of experience with Microsoft Office applications, and strong technical aptitude
EMR experience and proficiency
BSN or ADN degree
Preferences
Previous experience working with the geriatric population/ chronic condition experience
Home Health experience
Triage experience
Case management experience
Previous customer service experience
Previous experience in a telephonic role
Highly organized, self-directed worker with an ability to function in high volume environment
Strong verbal and written communication skills
Prior clinical experience in palliative care, end of life, hospice, oncology, ICU, geriatrics is preferred.
Knowledge of STARS and Hedis metrics a plus
IDEAL CANDIDATE:
Willing to travel inside Philadelphia area
Perform home visits with patients enrolled in At Home Care Chronic Risk Program and/or Advanced Care program (ACP)
Provides up-to-date health care advice/education regarding health promotion, illness prevention, and management of disease utilizing nursing assessment data, patient, family, and approved At Home Care Triage protocol. Considers the physical, cultural, psychosocial, spiritual, age-specific and educational needs of the patient.
Systematically assesses patients' actual or potential health care needs, prioritizes their urgency and uses creative and effective problem solving/decision making while recommending an appropriate disposition per clinician and protocol direction.
Documents nursing assessment, planning, implementation in the electronic health record. Documentation is timely and in accordance with policy. Evaluates the patients' and family's response to teaching. Documentation includes presenting problem, nursing assessment interventions, education and patients' response to interventions/treatments and education.
Makes follow-up telephone calls to patients and referrals as appropriate.
Provide telephonic nursing assessment and triage supported by triage protocols. This includes, timely and accurate triage documentation, escalation, and follow up
Initiate medication changes and other orders, as directed by provider in response to a triage call.
Health Literacy Improvement
Improves Health literacy and coaches consumers on chronic conditions including disease process and trajectory, medication education including possible side effects, plan of care, and individualized care goals management in a culturally sensitive and acceptable manner for the patient or caregiver.
Identifies problems or gaps in care, and offers opportunity for intervention
Coordinates services and referrals to health programs, and participates in patient education and outreach tied to HEDIS initiatives
Works to improve access to care, and works as part of the team to manage heath care cost and utilization
Provider Support
Completes telephonic nursing assessments including social determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider
Assists with organizing and running a chronic care and/or interdisciplinary care team rounds where high risk patients and care plans are identified
Participate using a team approach to create a care plan for the patient
Maintain and update spreadsheets and documents provided by health plan to prep weekly rounds of documentation
Post-Acute Management and Coordination
Participation in weekly care coordination with health plan case management as directed by market needs
Referral Management Care Coordination and tracking of hospice consults within 24 hrs. of order placement
Qualifications
Requirements:
Active, unrestricted RN license in Pennsylvania
Ability to obtain compact license and/or additional state licensure as needed
3 or more years of experience as a Registered Nurse
Proficient level of experience with Microsoft Office applications, and strong technical aptitude
EMR experience and proficiency
BSN or ADN degree
Preferences
Previous experience working with the geriatric population/ chronic condition experience
Home Health experience
Triage experience
Case management experience
Previous customer service experience
Previous experience in a telephonic role
Highly organized, self-directed worker with an ability to function in high volume environment
Strong verbal and written communication skills
Prior clinical experience in palliative care, end of life, hospice, oncology, ICU, geriatrics is preferred.
Knowledge of STARS and Hedis metrics a plus
