Value-based Care Registered Nurse (Per Diem)

Herself Health•Remote, MN, MN

5h•Remote

About The Position

Within a value-based and patient-centered model of care reporting to the Company's Lead Registered Nurse, the Registered Nurse (RN) at Herself Health provides exceptional care to women ages 65 and up. Through Transitional Care Management and Triage, the RN educates and empowers women to manage their health conditions and achieve their individual goals of care. The RN role facilitates collaboration and continuity of care among team members, including providers, medical assistants, and health coaches.

Requirements

An active, unrestricted Minnesota RN license required, or ability to obtain by start date. Multi-state compact license preferred
Willingness to obtain additional cross-state licensure as needed
Minimum of 2 years’ experience as an RN in clinical setting
Prior experience working as a triage RN or RN case manager required
Exceptional communication skills and patient-centered focus
Ability to monitor and evaluate opportunities for cost-effective care with high-quality outcomes
Demonstrate effective, independent nursing judgement and skills
Demonstrate skill and experience in effectively collaborating with care team members
Demonstrate skill in effective use of electronic health records
Demonstrate flexibility, organization, and appropriate decision-making in ambiguous situations

Nice To Haves

Prior experience working in telephonic case management preferred
Knowledge of Medicare and NCQA regulatory transitions of care preferred
Experience in value-based care preferred

Responsibilities

Reviews daily ADT feeds and initiates contact with patients within 2 days of discharge
Schedule follow-up for TCM visit with the PCP within 7 days of discharge
Complete weekly outreach for 30-day post-discharge
Review discharge plan and ensures services (e.g. Physical Therapy, Home Health) are in place; provides community resources for SDOH (Social Determinants of Health) needs
Provides patient/ family education regarding health conditions and disease self-management
Completes medication reconciliation and monitors adherence
Documents all telephone/ video interactions in EHR patient chart
Identifies patterns and episodes of care that are predictive of future needs and services
Coordinates care with other providers involved in the patient’s care as needed
Respond to patient telephone calls, refill requests, and electronic health messages
Demonstrates critical thinking skills and expert nursing judgement to provide appropriate recommendations for care utilizing an approved evidence-based telephone nursing triage protocol
Works with the RN scope of practice and standing orders to provide prescription refills, medication titration, and home treatments
Educates patient regarding test results and medical conditions, and explains medical terms and procedures
Maintains a professional demeanor and focus on patient-centered care