Care Team Nurse - RN
Company: Upward Health of Rhode Island PC
Location: San Mateo
Posted on: January 27, 2023
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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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