Field RN- At Home Care- Must reside in Philadelphia, PA

Cigna - Philadelphia, PA

Full-time - Mid Level

Hybrid - Philadelphia, PA

Insurance Carriers and Related Activities

About the position

The Field RN position in the At Home Care program is a vital role focused on providing comprehensive nursing care to patients in their homes. This position primarily involves conducting in-home visits, performing nursing assessments, triaging patients, coordinating care, and educating patients and their families about health management. The Field RN will support healthcare providers and address client-facing needs within the designated market area. In this role, the RN will perform home visits for patients enrolled in the At Home Care Chronic Risk Program and the Advanced Care Program (ACP). They will provide current healthcare advice and education regarding health promotion, illness prevention, and disease management, utilizing nursing assessment data and established triage protocols. The RN will consider various factors affecting the patient, including physical, cultural, psychosocial, spiritual, age-specific, and educational needs. The RN will systematically assess patients' healthcare needs, prioritize them, and employ effective problem-solving skills to recommend appropriate actions based on clinician protocols. Documentation of nursing assessments, planning, and implementation will be conducted in the electronic health record, ensuring compliance with policy and timely updates. The RN will also make follow-up calls to patients and manage referrals as necessary. Additionally, the RN will engage in telephonic nursing assessments and triage, ensuring accurate documentation and follow-up. They will initiate medication changes as directed by the provider and work to improve health literacy among patients regarding chronic conditions, medication education, and individualized care goals. The RN will coordinate services and referrals to health programs and participate in patient education initiatives tied to HEDIS metrics. The role also includes provider support through telephonic assessments, organizing chronic care team rounds, and maintaining documentation for care coordination. The RN will participate in weekly care coordination meetings and manage referrals, ensuring timely tracking of hospice consults. This position requires a proactive approach to patient care and collaboration with healthcare teams to enhance patient outcomes.

Responsibilities

• Conduct in-home visits for patients enrolled in the At Home Care Chronic Risk Program and Advanced Care Program (ACP).
• Provide health care advice and education regarding health promotion, illness prevention, and disease management.
• Systematically assess patients' healthcare needs and prioritize them based on urgency.
• Document nursing assessments, planning, and implementation in the electronic health record in a timely manner.
• Make follow-up telephone calls to patients and manage referrals as appropriate.
• Provide telephonic nursing assessment and triage supported by triage protocols.
• Initiate medication changes and other orders as directed by the provider.
• Improve health literacy and coach consumers on chronic conditions and medication education.
• Identify problems or gaps in care and offer opportunities for intervention.
• Coordinate services and referrals to health programs and participate in patient education tied to HEDIS initiatives.
• Complete telephonic nursing assessments including social determinants of health screenings and post-hospital discharge screenings.
• Assist with organizing and running chronic care and interdisciplinary care team rounds.
• Participate in creating care plans for patients using a team approach.
• Maintain and update spreadsheets and documents for weekly rounds of documentation.
• Participate in weekly care coordination with health plan case management as directed.
• Manage referral tracking and care coordination for hospice consults.

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

Benefits

• Sign-on bonus available.
• Health insurance coverage.
• Flexible scheduling options for work.
• Support for continued education and professional development.