Value-based Care Registered Nurse
H
Herself HealthPrimary Care
Remote, MNPart-TimeEntry
SalaryAt least 35 USD per hour
Apply NowOpens the employer's application page
Job Details
- Experience
- Minimum of 2 years’ experience as an RN in clinical setting
- Required Skills
- Communication SkillsEHR
Requirements
- An active, unrestricted Minnesota RN license required, or ability to obtain by start date
- Multi-state compact license preferred
- Willingness to obtain additional cross-state licensure as needed
- Minimum of 2 years’ experience as an RN in clinical setting
- Prior experience working as a triage RN or RN case manager required
- Exceptional communication skills and patient-centered focus
- Ability to monitor and evaluate opportunities for cost-effective care with high-quality outcomes
- 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
- Prior experience working in telephonic case management preferred
- Knowledge of Medicare and NCQA regulatory transitions of care preferred
- Experience in value-based care preferred
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
- Coordinates care with other providers involved in the patient’s care as needed
- Triage: Respond 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
- Educates patient regarding test results and medical conditions, and explains medical terms and procedures
- Maintains a professional demeanor and focus on patient-centered care
View Full Description & ApplyYou'll be redirected to the employer's site
