RN Case Manager (Remote)

Description

Field Based - Case Manager (RN)- Must Live in Greater Greensboro, NC

Apply directly: https://recruiting.paylocity.com/recruiting/jobs/Apply/1454758/UpStream-Primary-Care/Field-Based---Case-Manager-Registered-Nurse---10k-Sign-On

At UpStream we believe good health is a state of independence where each person has the capacity to live a long, happy, and active life. We aim to deliver the type of care our members need to regain and maintain their independence by delivering effective, efficient, and sustainable care. UpStream is a trusted partner to primary care physicians, helping them focus on what is most important, the patient. We support the delivery of value-based care for seniors and people living with chronic conditions. By working in partnership with healthcare practices and clinics we offer a comprehensive solution for physicians that delivers and sustains better outcomes.

Looking for a way to leverage your nursing skills, practice proactive patient care, and join an innovative healthcare company? If you are interested in an opportunity to expand the way you care for patients and join a team of proactive providers, this may be the company for you. We are a growing company and are excited to invite caring, detailed, and patient-centric Registered Nurses to join our clinical teams.

UpStream’s Registered Nurses (RNs) work closely with patients and Interdisciplinary Clinical Team (ICT) members to support the ongoing and coordinated care of UpStream’s patient population. As an integral member of the ICT, the RN moves between providing high quality care in patients homes and within a clinic setting to support the ongoing and coordinated care of UpStream’s patient population. As a member of an Interdisciplinary Clinical Team (ICT), the RN serves as the clinical lead for a select patient population who meet predefined, health criteria. As the clinical lead for the patient, the RN works directly with each patient to co-create a patient Care Plan aimed at resolving and preventing critical events, controlling chronic conditions, decreasing avoidable hospital admissions (and readmissions), ensuring safe care transitions, and improving self-management skills. Each member of the ICT contributes to the attainment of these goals.

RN's are an integral member of the ICT and contribute to UpStream’s patient-centric, emotionally-intelligent, and relationship-based culture. We seek individuals interested in positively contributing to this culture and growth.

This position requires confidentiality, discretion, critical-thinking, and exceptional patient service.

Day in the life:

• On average 70% field based, and 30% clinic based
• Daily schedule in the Electronic Medical Record
• Dayshift (approximately 8am - 5pm Monday - Friday)
• UpStream Car provided for work purposes
• UpStream uniform supplied
• Weekly education and professional development

Duties and Responsibilities:

In conjunction with the primary care provider and in collaboration with an Interdisciplinary Clinical Team (ICT), the following key care management services are performed by the Registered Nurse. Each of these services has standardized protocols of delivery and documentation.

• Outreach and health promotion services that are offered in the patient’s home environment, in the primary care office or telephonically
• Comprehensive assessment with required EMR documentation
• Development and implementation of an individualized care plan based on the patients’ and clinicians’ goals of care.
• Disease management of high- risk chronic conditions.
• Coordination of referrals and transitions of care from one provider to another or from one care setting to another to include evaluation of need to escalate level of care setting.
• Medication reconciliation and adherence
• Implementation of PCP and ICT prescribed medical interventions, including but not limited to wound care, pharmacologic therapy, intravenous medication and fluid administration, respiratory treatments, and home phlebotomy
• Facilitation and/or procuring timely access to appointments and services required by patient
• Patient and family/caregiver education
• Evaluation of effectiveness of care plan with ICT and the Care & Quality Team together with the patient, evaluates baseline medical and psychosocial risks and creates individualized patient care/treatment plans to be carried out by transition care specialists, pharmacists, clinical medical assistants, care coordinators, and/or partners with primary care and specialties
• Evaluation of need for additional homebased diagnostic services
• Assesses patient/family abilities to self-engage and develops individualized patient/family education plan focused on development of self-management skills based on standard care protocols
• Advises/educates patient, family/caregiver on importance of medication adherence and helps facilitate the removal of adherence barriers
• Early identification of patients with special needs and facilitates integration of primary care with specialty and other services such as behavioral, social, and community services where appropriate
• Plans, develops, assesses, and evaluates care provided to specific patient populations and engages team of transitional care specialist(s) and care coordination to divide workload among team where appropriate
• Recommends alternative levels or modalities of care and ensures compliance with federal, state, and local requirements
• Advocates the completion of living wills and advance care planning and where appropriate begin palliative care consults
• Develops and collects data; analyzes utilization of health care resources, including interpretation and application to case load decision making where appropriate
• Performs analysis of the effectiveness and appropriateness of patient care plan; and modifies care plan based on assessment and evaluation.
• Communicates clear, complete, and accurate documentation in a health record to ensure that all those involved in a client’s care have access to information upon which to plan and evaluate their interventions
• Updates plan of are timely to ensure all members of the care team have timely information regarding the patients’ status
• Leads team pre-visit planning activities including inpatient post-discharge activities and participates in daily huddles of ambulatory practice(s) where assigned

Requirements

• Registered Nurse with bachelor’s degree or equivalent with a minimum of 3 years direct practice experience
• Experience in critical care, emergency care, or home health care highly preferred
• Previous experience as a Registered Nurse, Care Manager, or in Acute Care Management
• Understanding of population health management preferred
• Excellent patient service skills
• Ability to maintain a positive attitude and personally connect with patients, caregivers, and fellow team members
• Must be able to work independently and interdependently within a team
• Developed analytical and critical thinking skills
• Excellent written and verbal communication skills
• Strong attention to detail
• Must be self-motivated and adaptable to changing processes
• A desire to be part of something bigger than oneself
• Experience using multiple electronic medical records
• Adept at using Microsoft 365, Word, Excel, and Outlook

To protect the health and safety of our workforce, patients, and communities we serve, UpStream requires all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UpStream will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

$10,000 Sign on bonus for external candidates who reside in Asheboro, NC.

Job Type: Full-time

Pay: $85,000.00 - $110,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Medical specialties:

• Critical & Intensive Care
• Geriatrics
• Home Health
• Hospice & Palliative Medicine
• Primary Care
• Wound Care

Schedule:

• Day shift
• Monday to Friday

Work setting:

• Clinic
• Office
• Remote
• Telehealth

Experience:

• Nursing: 3 years (Preferred)
• Case management: 3 years (Preferred)

License/Certification:

• RN (Preferred)

Willingness to travel:

• 75% (Preferred)

Work Location: Remote

Salary : $85,000 - $110,000