Registered Nurse

About the role

The RN 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.
• Tracks nursing care plan outcomes, interventions, and continues 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.
• Provides 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.
• Demonstrate an ability to identify and shift priorities within work assignment to effectively manage patient care load.
• 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.
• Collaborate with other business divisions to learn their needs, internalize their knowledge, and define solutions to achieve the business objectives of Care at Home.
• Provide subject matter expertise in the clinical solutions, including determining and recommending approaches for highest quality medical care, including assessment and event-based care management.
• Create a productive, collaborative, safe and inclusive work environment for the clinical team and as part of the larger Company.

Qualifications

• BSN Required. MSN or other healthcare related graduate level degree, a plus.
• 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.
• Experience with EMRs.
• BLS certification.