Registered Nurse Health Advisor

About the role

Maintains a collaborative approach with the interdisciplinary care team, supervisor, manager, director of health management, and/or medical director.

Identifies high-risk clients; monitors, assesses, and evaluates health care and psychosocial needs; and coordinates care and services between healthcare providers.

Develops and implements individualized care plans with immediate and long-term goals, documenting interventions and activities consistent with care management goals.

Adheres to case management standards of practice and follows evidence-based clinical guidelines to promote quality care and cost-effective outcomes.

Assesses clients' activation stage, literacy level, and self-management capabilities, and refers them to appropriate interdisciplinary care team members or community resources.

Facilitates advanced care planning and collaborates with behavioral health services to prevent unnecessary hospitalizations and readmissions.

Educates clients and families on diagnoses, medications, medication reconciliation, and nutrition to promote self-management.

Monitors and documents clients' responses to interventions and progress, using motivational interviewing to facilitate positive behavior change and goal achievement.

Collaborates with the interdisciplinary care team to develop person-centered care plans that prevent avoidable hospitalizations and emergency department visits.

Provides referrals to licensed clinical health workers, pharmacists, spiritual, and community resources as needed.

Accurately submits required documentation in a timely manner, ensuring compliance with department processes and procedures.

Supports department and health transformation team goals by providing quality interventions, excellent customer service, and maintaining acceptable attendance, productivity, and caseload expectations.

Responsibilities

• Maintains a collaborative approach with the interdisciplinary care team, supervisor, manager, director of health management, and/or medical director.
• Identifies high-risk clients; monitors, assesses, and evaluates health care and psychosocial needs; and coordinates care and services between healthcare providers.
• Develops and implements individualized care plans with immediate and long-term goals, documenting interventions and activities consistent with care management goals.
• Adheres to case management standards of practice and follows evidence-based clinical guidelines to promote quality care and cost-effective outcomes.
• Assesses clients' activation stage, literacy level, and self-management capabilities, and refers them to appropriate interdisciplinary care team members or community resources.
• Facilitates advanced care planning and collaborates with behavioral health services to prevent unnecessary hospitalizations and readmissions.
• Educates clients and families on diagnoses, medications, medication reconciliation, and nutrition to promote self-management.
• Monitors and documents clients' responses to interventions and progress, using motivational interviewing to facilitate positive behavior change and goal achievement.
• Collaborates with the interdisciplinary care team to develop person-centered care plans that prevent avoidable hospitalizations and emergency department visits.
• Provides referrals to licensed clinical health workers, pharmacists, spiritual, and community resources as needed.
• Accurately submits required documentation in a timely manner, ensuring compliance with department processes and procedures.
• Supports department and health transformation team goals by providing quality interventions, excellent customer service, and maintaining acceptable attendance, productivity, and caseload expectations.

Requirements

• Comprehensive knowledge and understanding of chronic and acute disease conditions, management, and treatment
• Ability to interact effectively with health care professionals and clients/caregivers
• Excellent written and verbal communication, interpersonal, critical thinking, and problem-solving skills
• Computer knowledge/skills and proficiency in applications such as Microsoft Outlook, Word, and Excel

Qualifications

• Associate's of Nursing
• Bachelor's of Nursing
• Field Of Study Nursing
• 5+ years of clinical experience as a registered nurse
• 2+ years of case management, care coordination, or transitions of care

Skills

• Knowledge of chronic and acute disease conditions, management, and treatment
• Interpersonal and communication skills
• Problem-solving and critical thinking skills
• Computer skills

Benefits

Includes medical, dental, vision insurance, life insurance, disability insurance, paid time off, retirement plan, and other employee benefits.

Pay

$68,132.50 - $119,520.35

Schedule

Full time, Day shift