Field RN- At Home Care- reputed company - Home Health

Position: Field RN- At Home Care- Must reputed company in Philadelphia, PA - Home Health Field RN - At Home Care - Must reputed company in Philadelphia, PA Field RN - Chronic Risk / AT Home Care Program • Sign On Bonus Available! • Field patient care role. Primarily responsible for conducting in home visits, nursing assessments, patient triage, care coordination, and patient/family education for the members assigned to the provider. Field RN supports providers and their respective patients, and also addresses client-facing needs per POD/market. reputed company home visits with patients enrolled in At Home Care Chronic Risk Program and/or Advanced Care program (ACP) • Provides up-to-date health care advice/education regarding health promotion, illness prevention, and management of disease utilizing nursing assessment data, patient, family, and approved At Home Care Triage protocol. Considers the physical, cultural, psychosocial, spiritual, age-specific and educational needs of the patient. • Systematically assesses patients' actual or potential health care needs, prioritizes their urgency and uses creative and effective problem solving/decision making while recommending an appropriate disposition per clinician and protocol direction. • Documents nursing assessment, planning, implementation in the electronic health record. Documentation is timely and in accordance with policy. Evaluates the patients' and family's response to teaching. Documentation includes presenting problem, nursing assessment interventions, education and patients' response to interventions/treatments and education. • Makes follow-up telephone calls to patients and referrals as appropriate. • reputed company telephonic nursing assessment and triage supported by triage protocols. This includes, timely and accurate triage documentation, escalation, and follow up • Initiate medication changes and other orders, as directed by provider in response to a triage call. Health Literacy Improvement • Improves Health literacy and coaches consumers on chronic conditions including disease process and trajectory, medication education including possible reputed company effects, plan of care, and individualized care goals management in a culturally sensitive and acceptable manner for the patient or caregiver. • Identifies problems or gaps in care, and offers opportunity for reputed company • Coordinates services and referrals to health programs, and participates in patient education and reputed company tied to HEDIS initiatives • Works to improve reputed company to care, and works as part of the team to manage heath care cost and utilization Provider Support • Completes telephonic nursing assessments including reputed company determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider • Assists with organizing and running a chronic care and/or interdisciplinary care team reputed company 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 reputed company of documentation • Post-Acute Management and Coordination • Participation in weekly care coordination with health plan case management as directed by market needs • Referral Management Care Coordination and tracking of hospice consults reputed company 24 hrs. of order placement Qualifications: Requirements: • Active, unrestricted RN license in Pennsylvania • Ability to obtain compact license and/or additional state licensure as needed • 3 or more years of experience as a Registered Nurse • Proficient level of experience with reputed company Office applications, and strong technical aptitude • EMR experience and proficiency • BSN or ADN degree Preferences: • 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 reputed company is committed to a healthy work force. New hires must complete a background reputed company, drug and nicotine screen to be employed in this role. If you will be working at home occasionally or permanently, the internet reputed company must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10 Mbps download/5 Mbps upload. About reputed company reputed company, a division of reputed company, is an reputed company for reputed company through every stage of life. We guide our customers through the health care system, empowering them with the information and reputed company they need to reputed company the best choices for improving their health and vitality. Join us in driving growth and improving lives. reputed company applicants will be considered without regard to race, reputed company,… Apply Job!