Homebound Outreach & Quality Nurse / RN - Full Time

East Liberty Family Health Care Center•Pittsburgh, PA

6d•Hybrid

About The Position

We are a faith-based Federally Qualified Health Care Center that serves multiple communities in the East-End section of Pittsburgh, PA. Our mission is to provide quality health care to those who are underserved, underinsured and uninsured. We are looking for a Homebound Outreach and Quality Nurse to join our team! This role will provide nursing services to our Homebound patients and telephonic case management for patients with multiple chronic conditions. Qualified candidates who are bilingual in English/Spanish are strongly encouraged to apply. COVID and influenza vaccines are required. Position is full time at 40 hours per week.

Requirements

RN degree and current State Nursing Licensure.
3 years Home Care experience required.
Valid Driver's License, Insurance and ability to commute to patient homes for visits.
Knowledge of Electronic Medical Records documentation and management

Nice To Haves

Geriatric nursing experience and MD office experience preferred
Behavioral Health experience is a plus.
eCW knowledge a plus.
Working knowledge of CMS Chronic Care Management, community-based resources are a plus.

Responsibilities

Screen physician referrals to the Homebound Program. Evaluate the referral based on program description and patient's need.
Screen patient charts and update demographics including consents, sliding fee scale, contacts and insurance
Evaluate patient's ongoing need for Homebound services based on program description.
Discharge patients from the Homebound program according to discharge criteria outlined in the program description.
Learn and implement the Chronic Care Management Program for ELFHCC Clients and track time.
Develop care plans and goals for clients and follow appropriately using the Chronic Care Module.
Visits patients in their home, take and record vital signs, obtain specimens, manage medications and perform laboratory testing per standing orders. Document results in the EMR in a timely manner.
Assist with monitoring and scheduling TCM (Transitional Care Management) patients.
Triage and respond to phone messages according to phone protocols. Document all calls before the end of the day.
Monitor practice performance according to HRSA UDS, Patient Centered Medical Home and Health Plan quality standards, including programs for unconfirmed diagnosis codes and quality measures/gaps in care.
Use reports available within the EMR as well as information obtained from Health Plans to identify patients who are overdue for preventative screenings.
Perform chart reviews and audits (HRSA UDS, ELFHCC Peer Review, HEDIS, Health Plans, etc.).
Assist in the preparation of reports for the QI/QA Committee, Leadership Committee, Practitioners and Nursing Staff meetings.
Must have a desire to serve the underserved in the East Liberty/Lincoln-Lemington areas of Pittsburgh.