Registered Nurse (0767)

About the role

The Registered Nurse (RN) at Grace at Home reports to the Clinical Manager or designee, with accountability for providing strategy, judgment, organization, and evidenced-based analysis to influence decisions, and directly to meet Grace at Home’s requirements. They should embody Grace at Home’s core values, including, Trusted, Empathetic, Committed, Humble, Creative and Community-Minded.

Responsibilities

• Works with member and care team to conduct appropriate assessments that result in a nursing care plan prioritized by the patient and caregivers.
• Conducts in-home or tele-health assessments, as directed by the model and leadership.
• Track nursing care plan outcomes, interventions, and continue to reassess the patient's needs as appropriate.
• Utilizes care pathway templates by condition with risk levels and member actions by event type.
• Deploys Remote Patient Monitoring and Patient Self Reporting for High-Risk Chronic Conditions.
• Conducts transition of care visits both virtually and in-home to ensure smooth transition from an acute care setting to home.
• Provide care coordination for Grace at Home’s Family Members including patient navigation, chronic disease management/education and interdisciplinary collaboration while complying with department policies and procedures and other contractual requirements.
• Engage members in taking a proactive role for managing their health, medications, treatment and mental health needs, and follow-up appointments and refer patients to the appropriate community-based organizations or other programs.
• Follow evidence-based guidelines to facilitate closure of gaps in care and encourage and use of in-network services if appropriate and determine when in-home services are needed and ordered.
• Use the electronic medical record or clinical management platform to conduct care coordination activities and comply with associated policies and procedures including those for workflow and consistent documentation.
• Participate in team-based rounds to support and contribute to ongoing program design and development as lessons are learned from the field and process improvement work performed within the department.
• Demonstrates an ability to identify and shift priorities within work assignment to effectively manage patient care load.
• Perform other job-related duties as assigned.
• Leadership: The RN will lead in defining and executing strategies and solutions to create business value in the clinical practice, including working with their team to design, develop, and execute those strategies and solutions to deliver desired outcomes.
• Strategy: The RN will establish the business strategy and roadmap: (1) improve outcomes for Grace at Home Family Members; (2) enhance the efficacy of other Grace at Home business divisions; and (3) develop and deliver external market opportunities for Grace at Home products and services. In establishing the business strategy, the RN Advocate will define and innovate sustainable revenue models to drive profitability of the Company.
• Collaboration: The RN will ensure that our clinical capabilities form a cohesive offering, including by working closely with other business divisions to learn their needs, internalize their knowledge, and define solutions to achieve the business objectives of Care at Home.
• Knowledge: The RN will provide subject matter expertise in the clinical solutions, including determining and recommended approaches for highest quality medical care, including assessment and event-based care management.
• Culture: The RN is accountable for creating a productive, collaborative, safe and inclusive work environment for the clinical team and as part of the larger Company.

Qualifications

• Education: BSN Required. MSN or other healthcare related graduate level degree, a plus.
• Experience: At least 3 to 5 years of relevant clinical experience. Ideal candidates will have 3+ years of relevant care management experience in a health plan, hospital, home health and or hospice.
• Unrestricted RN licensure in the state of the hiring Grace at Home location; preferably an enhanced-compact-multi-state license (eNLC) to potentially support other locations, as necessary
• Knowledge and prior use of Microsoft Office products or other similar office software
• Unrestricted driver’s license in the state of hire
• Experience with EMRs
• BLS certification

Competencies

• Analytics/Critical Thinking: Ability to examine/analyze and evaluate information to form a reasoned judgement on the information presented.
• Assessment Skills: Utilize the nursing process to evaluate a member’s bio-psychosocial conditions. Use evidence-base practices as a model for care delivery.
• Problem Solving: Ability to identify a problem, consider options and implement a solution to achieve a desired outcome
• Communication: Excellent verbal, written communication, and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner.
• Relationships: Ability to build and effectively manage relationships with patients, the community business leaders, and external constituents.
• Culture: Good judgement, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial Company.