RN Coordinator- At Home Care- Hybrid- Philadelphia, PA

About the position

Responsibilities

• Be the point of contact for all aspects of the member in regard to their appointments, care, and overall health.
• Act as the liaison between the providers and their patient panel, directing and delegating tasks to team members.
• Educate patients about their care options and make specific recommendations based on their goals.
• Review paperwork for patients to ensure it meets all requirements.
• Explain test results, diagnoses and other medical outcomes.
• Cover any additional triage and transition of care for patients as needed.
• Improve health literacy and coach patients on chronic conditions including disease process and trajectory, medication education including possible side effects, plan of care, and individualized care goals management.
• Identify problems or gaps in care and offer opportunity for intervention.
• Coordinate services and referrals to health programs and participate in patient education and outreach tied to HEDIS initiatives.
• Work to improve access to care and manage healthcare costs and utilization.
• Complete telephonic nursing assessments including social determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider.
• Assist with organizing and running chronic care and/or interdisciplinary care team rounds where high risk patients and care plans are identified.
• Participate using a team approach to create a care plan for the patient.
• Maintain and update spreadsheets and documents provided by health plan to prep weekly rounds of documentation.
• Participate in weekly care coordination with health plan case management as directed by market needs.
• Manage referral coordination and tracking of hospice consults within 24 hrs. of order placement.
• Obtain Pre Authorization for all CT, MRI, Echo's ordered by providers.
• Serve as a guide in their POD for all escalated orders and results as clinically appropriate.
• Assess and triage immediate health concerns transferred to nursing team by clinical support staff.
• Provide telephonic nursing assessment and triage supported by triage protocols.
• Initiate medication changes and other orders, as directed by provider in response to a triage call.
• Monitor daily discharge list and develop a plan to schedule transition of care visits within the allotted timeframe.
• Complete telephonic post-discharge hospital visits and ask pertinent discharge triage questions and complete medication reconciliation.
• Document all findings and make appropriate referrals to social work, pharmacy, case management and engagement.

Requirements

• Active, unrestricted RN license in all states we provide services.
• Ability to obtain compact license and/or additional state licensure as needed.
• 3+ years of experience as a Registered Nurse.
• Proficient level of experience with Microsoft Office applications, and strong technical aptitude.
• EMR experience and proficiency.
• BSN or ADN degree.

Nice-to-haves

• Previous experience working with the geriatric population/ chronic condition experience.
• Home Health experience.
• Triage experience.
• Case management experience.
• Previous customer service experience.
• Previous experience in a telephonic role.
• Highly organized, self-directed worker with an ability to function in high volume environment.
• Strong verbal and written communication skills.
• Prior clinical experience in palliative care, end of life, hospice, oncology, ICU, geriatrics is preferred.
• Knowledge of STARS and Hedis metrics a plus.

Benefits

• Smoking cessation program

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