Value-based Care Registered Nurse (Per Diem)

About the role

The Registered Nurse (RN) at Herself Health provides exceptional care to women ages 65 and up. Through Transitional Care Management and Triage, the RN educates and empowers women to manage their health conditions and achieve their individual goals of care. The RN role facilitates collaboration and continuity of care among team members, including providers, medical assistants, and health coaches.

Responsibilities

• Transitional Care Management (TCM): Focused on outreach during the 30 days after discharge with the goal of reducing ER visits, hospitalizations, readmissions, and post-acute stays.
  • Reviews daily ADT feeds and initiates contact with patients within 2 days of discharge.
  • Schedule follow-up for TCM visit with the PCP within 7 days of discharge.
  • Complete weekly outreach for 30-day post-discharge.
  • Review discharge plan and ensures services (e.g. Physical Therapy, Home Health) are in place; provides community resources for SDOH (Social Determinants of Health) needs.
  • Provides patient/family education regarding health conditions and disease self-management.
  • Completes medication reconciliation and monitors adherence.
  • Documents all telephone/video interactions in EHR patient chart.
  • Identifies patterns and episodes of care that are predictive of future needs and services.
  • Captures care coordination with other providers involved in the patient’s care as needed.
• Triage: Responds to patient telephone calls, refill requests, and electronic health messages.
  • Demonstrates critical thinking skills and expert nursing judgement to provide appropriate recommendations for care utilizing an approved evidence-based telephone nursing triage protocol.
  • Works with the RN scope of practice and standing orders to provide prescription refills, medication titration, and home treatments.
  • Edits patient regarding test results and medical conditions, and explains medical terms and procedures.

Requirements

• An active, unrestricted Minnesota RN license required, or ability to obtain by start date.
• Multi-state compact license preferred.
• Prior experience working as a triage RN or RN case manager required.
• Exceptional communication skills and patient-centered focus.
• Demonstrate effective, independent nursing judgement and skills.
• Demonstrate skill and experience in effectively collaborating with care team members.
• Demonstrate skill in effective use of electronic health records.
• Demonstrate flexibility, organization, and appropriate decision-making in ambiguous situations.

Qualifications

• Minimum of 2 years’ experience as an RN in clinical setting.
• Prior experience working in telephonic case management preferred.
• Knowledge of Medicare and NCQA regulatory transitions of care preferred.
• Experience in value-based care preferred.