Performs Care management services for advancing risk and high-risk individuals
May perform home and hospital visits and travel time can occur 0%-25% of the time.
Mobilizes resources in coordination with team members to achieve expected goals per the member’s plan of care and ensures that patient diagnostics are appropriate, necessary and completed.
Leads multidisciplinary team meetings for review of the member’s plan of care, collaborating with team members to address member needs and desired outcomes complying with all associated regulatory requirements and policies.
Collaborates with Social Worker when members and their families are in need of financial counseling or other social needs.
Monitors hospitalized members and reports out at daily team huddle.
Completes transition of Care Management calls to members within 48 hours of a hospital discharge, and schedules follow up appointments within 5 business days of discharge.
Effectively completes or delegates tasks related to delivery of the Home Health Referrals, acquiring and tracking the Face-to-Face Evaluation, arrangements for home medical equipment when appropriate.
Performs Medication Administration, Wound Care, vital signs, ECG’s and various point of care testing as per providers orders when required.
Identifies and manages risks, resolves issues as they arise; reports and documents adverse events and reportable conditions.
Informs and assists physicians to ensure appropriate documentation exists to support Plan of Care.
Evaluates member satisfaction and intervenes/acquires resources to ensure member and family needs are met.
Serves as a member advocate and enhances a collaborative relationship between the physician and multidisciplinary team with the member and family to ensure needs are met.
Demonstrates understanding and proficiency in the management of denials and appeals.
Provides feedback to the multi-disciplinary team as necessary regarding the trending of any issues identified and collaboratively works to develop action plans to improve processes.
Demonstrates proficiency in use of the electronic medical record and programs specific to the role
Effectively functions as part of a self-directed work team
Participates in Performance Improvement activities.
Assists in training new clinical hires in the practice.
Actively participates in daily team huddles.
Complies with all HIPAA regulations.
Other duties as assigned.
KNOWLEDGE AND SKILLS REQUIRED:
Excellent verbal and written communication skills
Excellent interpersonal and teamwork skills
Flexibility and comfort with a young organization that is transitioning from its early startup phase to one with more structured processes
Proficient in Chronic Care Management
Ability to monitor, assess and record patients’ progress and adjust and plan accordingly
Knowledge of clinical and social services documentation procedures and standards
Ability to plan, implement and evaluate individual patient care plans
A supportive attitude toward our patient population of older adults
KNOWLEDGE AND SKILLS PREFERRED:
Critical thinking and judgment in the provision of clinical care
Case Management experience
Experience with wound care
EDUCATION AND EXPERIENCE REQUIRED:
Graduate from an accredited school of nursing
Two (2) years of hospital nursing experience
EDUCATION AND EXPERIENCE PREFERRED:
BSN or MSN degree
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
Registered Nurse (RN) license that is valid, current, and unencumbered.
Current, valid CPR certification is required
AdventHealth Senior Care is looking for team members with a passion to transform health care and make a difference in the lives of seniors. AdventHealth Senior Care is an innovative primary care practice delivering comprehensive, high quality, team-based care for our members and their families. Our relationship-based care model is designed to provide coordinated health care through a curated network that improves the quality and outcomes in the communities we serve. Our member-centered approach focuses on individualized care to meet the unique needs of our members and is supported by our dedicated care team of primary care physicians, health coaches, nurses and an array of specialized services. We strive for clinical excellence and aim to increase quality, increase patient satisfaction and reduce unnecessary utilization of health care resources. AdventHealth Senior Care is creating a new connection around how whole-person care is delivered to better meet the full spectrum of health care needs in this senior population.
AdventHealth Senior Care is looking for a Registered Nurse to be responsible for achieving and leading a high-quality care experience for the member throughout the health care system. The Registered Nurse serves as an advocate for the member and builds trusting relationships with the members’ families and care givers to manage the member’s care plan. The Registered Nurse supports care team decision making and partners with primary care physicians, specialists, social workers and other care providers to develop care plans and coordinates members to the appropriate/least constrictive level of care. The Registered Nurse ensures continuous excellence by strictly adhering to departmental goals/objectives, performance standards and compliance with policies and procedures. The Registered Nurse is an important part of AdventHealth Senior Care’s success to deliver accessible, high-touch primary care and coordinated care for Senior Care members.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.