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Care Team Nurse - RN

Company: Upward Health of Rhode Island PC
Location: San Mateo
Posted on: January 27, 2023

Job Description:

Description:CARE TEAM NURSEUpward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs. We serve patients throughout their communities, and we diagnose, treat, and prescribe anywhere our patients call home. We reduce barriers to care such as lengthy delays due to scheduling. We see patients when they need us, for as much time as they need, bringing care to them. Beyond medical supports, we also assist our patients with challenges that may affect their health, such as food insecurity, social isolation, housing needs, transportation and more. It is no wonder 98% of patients report being fully satisfied with Upward Health!Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission. Or you could join us and experience it all for yourself.WHY IS THIS ROLE CRITICAL?The Care Team Pod is a multidisciplinary team of licensed and unlicensed staff who provide direct support and care to Upward Health's patients. The Care Team Pod is comprised of a diverse team that may include medical providers, nurse practitioners, registered nurses, licensed social workers, pharmacists, therapists, and care specialists. This team works within the community and in the patients' homes or meet in agreed upon locations in the community. The Care Team Nurse is responsible for the direct care of an assigned cohort of high-risk patients, as well as the development, implementation and ongoing monitoring of care plans and outcomes for those patients. This role will demonstrate a commitment to effective and efficient care leading to high quality outcomes, while managing the total cost of care. The focus is to deliver care in the home, or the most optimal level of safe and effective site of care.The Care Team Nurse acts as a liaison between patients, their families, doctors, and ancillary health care providers ensuring the patient, family and caregivers understand the care plan and can progress towards self-care wherever possible. The Care Team Nurse will serve in a direct care and patient advocacy role and will ensure interdisciplinary care is optimized toward targeted outcomes. The Care Team Nurse works directly with the patient in the field, i.e., member's home, provider's office, hospitals, etc., while collaborating with the Clinical Operations team to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the patient. For some patients, the Care Team Nurse implements chronic care management, complex chronic care management, and/or intensive case management and care coordination efforts to support and guide the patient through their journey within the healthcare ecosystem of providers, hospitals, outpatient services, etc. In collaboration with the Care Transitions Nurse who is monitoring for Remote Patient Monitoring (RPM) alerts, the Care Team Nurse will take immediate action for abnormal or out-of-range patient results.KEY RESPONSIBILITIESAssess, evaluate, and provide for the ongoing monitoring of patient care coordination and delivery that results in optimized quality, clinical and financial outcomesComplete comprehensive assessments and develops care plans utilizing clinical expertise to evaluate the patients need for Upward Health and additional servicesDevelop a relationship of safety and trust with transparent communication between the patient, caregivers, and the care teamIdentify, acknowledge, and advocate for the needs of the patientBuild a patient-centric care plan and environment that incorporates the needs of the patientReview the patient diagnoses and facilitate the coordination of treatment plans of the PCP, specialists, and interdisciplinary care team - Attend Interdisciplinary Team (IDT) roundsEvaluate patient outcomes with respect to the medical record, patient and family history and available healthcare utilization informationContinuously monitor and update care plans and coordinate care across providersEducate patients and families about treatment plans and optionsAccurately document and submit medical documentationMaintain knowledge of diagnoses, signs and symptoms of disease, standard therapy protocols derived from evidence-based outcomes, medications, and warning signs of non-optimal patient outcomesProvide guidance and support to patients and families inclusive of community-based support programsReview results from medical tests (lab, imaging, etc.) and ensure visibility across all care providers including escalation of abnormal or out-of-range findingsImplement physician orders - ensuring a linkage between all care providers throughout a patient's episodes of careCommunicate patient progress by conducting regular interdisciplinary meetings and evaluations, disseminating results and obstacles to the healthcare team and familyFunction as a resource for non-clinical staff including first point of contact for patient triage and with escalation to the provider(s) as neededCoordinate community resources, with emphasis on medical, behavioral, and social servicesApply case management standards, maintains HIPAA standards and confidentiality of protected health information, and reports critical incidents and information regarding quality-of-care issuesMeet with patients in their homes, worksites, physician's offices, or hospital to provide management of servicesParticipate with other care team members in regular or special meetings such as Clinical roundsPerform other duties as assignedKNOWLEDGE, SKILLS & ABILITIESInterpersonal savvy, with the demonstrated ability to interact with and influence people to establish trust and build strong relationshipsA high sense of urgency and can-do attitude required for a role at a start-up companyStrong organization skills and ability to manage and maintain a personal scheduleAbility to establish priorities and meet deadlinesAbility to work independently within a virtual operating environment and as part of a teamExcellent oral and written communication skillsAbility to conduct written and oral instructionsAbility to exercise judgment in the application of professional servicesRequirements:REQUIRED QUALIFICATIONSUnrestricted registered nursing license in the state(s) of care management activities a minimum requirementTravel to patient's home, provider's office, hospitals, etc., required with dependable carMust be willing to spend 70% of time traveling in the fieldDemonstrated expertise in care management and coordination across all healthcare providers, patient, and caregiversExperience with completing real-time documentation in EHR and/or Care Management systemsAbility to effectively communicate across a multitude of key care partnersAbility to motivate patients and caregivers to follow care plans and optimize self-care potentialExcellent documentation skills with the ability to manage multiple patient casesSound critical thinking to assess, analyze and monitor outcomes to recommend the optimal plan of careComputer literacy and ability to effectively communicate within the business structurePREFERRED QUALIFICATIONS3+ years of care management experience in an outpatient setting preferred3+ years in a hospital, health plan or related healthcare business entity also consideredExperience serving the Medicare, Medicaid, and Duals populationProven experience working independently seeing patients in the communityUpward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. All individuals selected for a position will undergo a background check appropriate for the position's responsibilities.**We require all our employees to be vaccinated and to show proof of vaccination upon hire**PM22PI202125702

Keywords: Upward Health of Rhode Island PC, San Mateo , Care Team Nurse - RN, Healthcare , San Mateo, California

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