Acute Care Nurse, HCT (RN)

We’re unique. You should be, too. We’re changing lives every day—for both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy? We’re different than most primary care providers. We’re rapidly expanding and need great people to join our team.

About the role

The Acute Care Nurse is responsible for achieving positive patient outcomes, managing quality of care across the continuum of care with efficient allocation of healthcare resources. This role will first and foremost serve as an advocate for our patients and families as they navigate through external providers and healthcare systems. The Acute Care Nurse is an important member of the Hospital & Community Care Teams and will use all available resources and leverage other members of the healthcare care team to develop effective plans of care with a focus on delivering high levels of longitudinal care coordination.

The Acute Care Nurse role also involves establishing relationships with patients’ families and caregivers, primary care physicians, hospitalists, specialists, social workers, other case managers and nurses, acute and post-acute facilities, home health care companies, and health plans. This position will focus on health promotion for a senior population by providing onsite hospital visits, communicating and coordinating care with hospitalists/hospital staff, and recommending appropriate levels of care (inpatient vs. observation). The Acute Care Nurse uses our internal charting system to report daily inpatient updates and works with the hospital team on expedited discharge planning to the next level of care. The Acute Care Nurse anticipates the need for post-acute and/or long-term care from day one of the hospital stay, providing support to all parties involved.

Daily updates in our charting system are required for each patient using the hospital’s EMR system and onsite reviews. The Acute Care Nurse follows the patient throughout the continuum of care when the patient discharges to a Skilled Nursing Facility (SNF) or Long-Term Care (LTC) to provide weekly updates on discharge and ensure that upon discharge, the patient is reconnected to the care of the primary care provider. The Acute Care Nurse provides a warm handoff to the Community Care Nurse when the patient is discharged to home and/or from post-acute care facilities. The Acute Care Nurse adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance, and policies and procedures.

Responsibilities

• Identifies appropriateness of inpatient vs. observation status.
• Identifies areas of opportunity regarding proper allocation of healthcare resources in acute and post-acute settings.
• Identifies and manages safety risks (complete a social assessment), identifies functional status (ADLs and PT needs), discusses medications and self-management, and identifies and corrects knowledge deficits.
• Conducts hospital bedside discussions explaining our Care Management/Disease Management program with a verbal introduction to their Community Care Manager for home visits once discharged to home from either inpatient or skilled nursing facility (SNF).
• Implements the ACM Coaching program with the appropriate patient population.
• Identifies from day one of hospital stay any barriers for a safe discharge back to the community.
• Seeks assistance from ChenMed’s Specialists when needed to support the care of our patients in healthcare facilities.
• In markets as appropriate, when the patient is in SNF, coordinates with the post-acute physician to transition to a lower level of care as soon as appropriate using a preferred provider if further services are needed.
• Facilitates discharge to the appropriate level of care and preferred providers.
• Communicates discharge to all stakeholders including patient, patient’s family or designee, PCP, Center Manager, and Community Care Nurse.
• Documents the appropriate date that the patient is medically discharged and updates as needed.
• Performs Social Determinates of Health (SDoH) screening with each patient on every admission and communicates to our Community Social Workers or PCPs when a need is identified.
• Identifies new diagnoses during acute stay and provides PCP documentation to review and add to the patient problem list.
• Contacts the center manager or designee to arrange for a 4-day follow-up PCP appointment prior to discharge and, whenever possible, communicates this information to the patient/caregiver.
• As appropriate, offers and discusses with patients the benefit of our CCM or DM programs and identifies patient interest in participation.
• Coordinates acute UR physician meetings.
• Performs other duties as assigned and modified at manager’s discretion.

Pay

Pay Range: $36.90 - $52.70 hourly. The posted pay range represents the base hourly rate for this position. Final compensation will depend on a variety of factors including but not limited to experience, education, geographic location, and other relevant factors. This position may also be eligible for bonuses or commissions.

Benefits

ChenMed offers comprehensive benefits, career development, and advancement opportunities. For more details, visit ChenMed Benefits.