Visiting Nurse

About the role

We are seeking a Registered Nurse to serve patients in the areas of 29501, 29506, 29505, 29532, and 29540. The role of the Visiting Nurse (Nurse Case Manager) is critical to the patient’s care team. The nurse will visit patients and facilitate with appropriate providers. The Nurse Case Manager will travel to patients' homes, long-term care facilities, etc., to evaluate patients and initiate telemedicine visits. The position requires reliable transportation due to daily travel.

Responsibilities

• Facilitate receiving all medical records from the patient’s primary provider and specialists.
• Review medical records.
• Complete consents with patients.
• Enroll patients in Care Management, if they meet eligibility criteria.
• Initiate a Care Management Plan of Care, if the patient is eligible.
• Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
• Complete AWV’s to be reviewed by the provider.
• Complete cognitive impairment screenings.
• Complete Social Determinants of Health (SDoH) assessments and/or screenings.
• Complete ACP’s to be reviewed with the patient by the provider.
• Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
• Evaluate for RPM devices, resources, or tools that may improve the patient’s quality of life.
• Communicate and coordinate care.
• Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments.
• Provide post-discharge education.
• Evaluate for adaptive equipment and DME.
• Evaluate for safe environment.
• Evaluation of acute condition(s) or follow-up from previous visit.
• Appropriately and accurately document and log Care Management activities.
• Work in conjunction with care team to keep the patients Care Management care plans up to date.
• On-call may be required.

Qualifications

• Must be a licensed nurse.
• Registered nurse preferred.
• Licence must be in good standing with appropriate board/issuer.
• A minimum of three (3) years clinical experience preferred.
• Experience in community settings preferred.
• Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
• Strong written and verbal skills.
• Basic computer knowledge.
• Ability to manage and demonstrate effective leadership skills.
• Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
• Ability to foster a cooperative work environment.
• Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
• Must be able to work flexible hours and travel between offices, facilities, etc.
• Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order.