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RN

Company: Upward Health
Location: Hauppauge
Posted on: May 3, 2022

Job Description:

Patient Care Nurse The Patient Care 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. Why is this role critical? The Patient Care 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 Patient Care Nurse will serve in a direct care and patient advocacy role and will ensure interdisciplinary care is optimized toward targeted outcomes. The Patient Care Nurse works directly with the patient in the field, i.e., inpatient bedside, member's home, provider's office, hospitals, etc. while collaborating with the Clinical Services team to assess, plan, implement, coordinate, monitor and evaluate services and outcomes to maximize the health of the patient. Responsibilities: Assess, evaluate, and provide for the ongoing monitoring of patient care coordination and delivery that results in optimized quality, clinical and financial outcomes Complete comprehensive assessments and develops care plans utilizing clinical expertise to evaluate the patients need for UH and additional services Develop a relationship of safety and trust with transparent communication between the patient, caregivers, and the care team Identify, acknowledge, and advocate for the needs of the patient Build a patient-centric care plan and environment that incorporates the needs of the patient Review the patient diagnoses and facilitate the coordination of treatment plans of the PCP, specialists, and interdisciplinary care team Evaluate patient outcomes with respect to the medical record, patient and family history and available healthcare utilization information Continuously monitor and update care plans and coordinate care across providers Educate patients and families about treatment plans and options Accurately document and submit medical documentation Maintain knowledge of diagnoses, signs and symptoms of disease, standard therapy protocols derived from evidence-based outcomes, medications, and warning signs of non-optimal patient outcomes Provide guidance and support to patients and families inclusive of community-based support programs Review results from medical tests and ensure visibility across all care providers Implement physician orders - ensuring a linkage between all care providers throughout a patient's episodes of care Communicate patient progress by conducting regular interdisciplinary meetings and evaluations, disseminating results and obstacles to the healthcare team and family Act as a resource for non-clinical staff Coordinate community resources, with emphasis on medical, behavioral, and social services. Apply case management standards, maintains HIPAA standards and confidentiality of protected health information, and reports critical incidents and information regarding quality-of-care issues Meet with patients in their homes, worksites, physician's offices, or hospital to provide management of services. Participate with other care team members in regular or special meetings such as Clinical rounds Perform other duties as assigned Required Qualifications Unrestricted registered nursing license in the state(s) of care management activities a minimum requirement Travel to patient's home, provider's office, hospitals, etc. required with dependable car Must be willing to spend 70% of time traveling in the field 3+ years of care management experience in an outpatient setting preferred. 3+ years in a hospital, health plan or related healthcare business entity also considered. Demonstrated expertise in care coordination across all healthcare providers, patient, and caregivers Experience with completing real-time documentation in EHR and/or Care Management systems Ability to effectively communicate across a multitude of key care partners Ability to motivate patients and caregivers to follow care plans and optimize self-care potential Excellent documentation skills with the ability to manage multiple patient cases Sound critical thinking and problem-solving skills to assess, analyze and monitor outcomes to recommend the optimal plan of care Computer literacy and ability to effectively communicate within the business structure Preferred Qualifications Experience serving the Medicare population Experience documenting in athenahealth Proven experience working independently seeing patients in the community Employment Type: Full Time Years Experience: 3 - 5 years Salary: $80,000 - $85,000 Annual Bonus/Commission: Yes

Keywords: Upward Health, Westport , RN, Healthcare , Hauppauge, Connecticut

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