Registered Nurse - Value Based Care

Registered Nurse - Value Based Care

General Job Summary: The RN tracks and monitor patients throughout their disease process while coaching them to best manage their disease process. The RN collaborates with the patient, support system, and PCP care team in coordination of care to ensure the patient receives the appropriate services while creating and managing care plans and goals. The RN identifies barriers and provides intervention to prevent gaps in care and avoidable hospital utilization and decomposition.

(This is a full time position that will support the Value Based Care team at our SouthPark office, Monday to Friday 8 am to 5 pm)

Primary Job Responsibilities/Tasks may include, but not limited to:

• Patient Care Planning – Create and collaborate on care plans for optimal condition management. Custodian of care plan.
• Patient Triage – Interrupt cycle of hospital utilization and condition mismanagement through proactive and reactive patient triage.
• Collaboration and Access – Serve as connection between patient and diverse services and service providers.

Key responsibilities include:

• For incoming patient triage requests, perform short evaluation of the patient situation to estimate severity and urgency of illness and/or injury including learning about chief complaint, patient’s history and, as possible, obtaining vital sign and mental status information.
• Initiate and manage care plans for patients enrolled in Chronic Care Management (CCM) and Transitional Care Management (TCM) value-based medicine programs.
• Responsible for conducting annual wellness visits via virtual / telephone or in-person.
• Collaborate with physician and pharmacist staff to optimize care plans and goals and assess the urgency of patient problems.
• Carry out clinical intake and interval care plan follow-up for enrolled patients in longitudinal and episodic care.
• Identify opportunities for optimization, connecting patients to clinical and community services as applicable.
• Coach and educate patient and caregivers to empower self-care and condition management.
• Support patient outcomes through activities such as survey initiation, interaction, and follow-up in addition to individual patient outreach per request. Record and maintain complete and accurate records of patient and physician communications regarding medical care.
• Submit electronically/fax new prescriptions and refill prescriptions according to physician orders.
• Serve as a resource to clinic staff regarding medical information, patient assessment, and nursing management of illness within skill level and scope of practice.
• Other duties as assigned.

Education, Experience and Certifications:

• Graduate of an accredited school of professional nursing. Bachelor's degree is preferred.
• Must be licensed as a Registered Nurse with the State of North Carolina.
• CPR Certification through the American Heart Association or American Red Cross required.
• Completion of Hepatitis B Vaccine and Flu Vaccine Form will be required. Candidate may decline vaccination through declination form or may provide record of vaccination from previous employer.
• Completion of TB test will be required.
• 3 or more years of experience in a medical setting, Primary Care preferred.
• Excellent customer service, computer, communication skills required.

Physical Requirements:

• Work may consistently require walking, standing, sitting, lifting, reaching, stooping, bending, pushing and pulling.
• Must be able to lift and support weight of 35 pounds
• Ability to concentrate on details.
• Use of computer for long periods of time.
• Must be able to speak and articulate clearly.