Resource RN - North Worcester County and South Middlesex County

Cityblock Health•Worcester, MA

1d•Hybrid

About The Position

The Resource RN provides nursing support to the care team, serving as a bridge between the care management team, hub-based clinical team and members. The Resource RN is available to support and consult on member-specific needs (e.g., in-person visits, clinical education, targeted clinical interventions), and is home based, meaning days will primarily be virtual, but can go into the field on occasion. The Resource RN does not carry a panel, however the RN may work lists of members for targeted clinical reasons.

Requirements

3+ Years of experience
Graduate of an accredited school of nursing (R.N.)

Responsibilities

Support the Member Navigator during the assessment and intake phase to ensure assessments are accurately interpreted and appropriately triaged.
Collaborate with care team members for case review and care planning, signing off on care plans, determining escalations, and resolving barriers to effective care.
Act as a clinical resource, assisting team members with clinical goals, education, and addressing acute clinical needs.
Conduct medication reconciliation, administration, compliance, and education during clinical visits and procedures, including processing medication refills per established protocols or provider orders.
Meet members in various community settings such as homes, SNFs, shelters, or hospitals, serving as an extender of care team providers and performing tasks like administering injections, monitoring vital signs, conducting global assessments, facilitating minor procedures, and in-home medication reconciliation.
Utilize preventive health screening tools and coordinate DME fit and education while providing in-home disease management education and wound assessments and care.
Perform blood draws and reinforce care plans for chronic conditions such as diabetes, hypertension, heart failure, and depression.
Address quality gaps prioritized by contracts and the organization, ensuring proper chart documentation and coding (ICD or CPT) as evidence of gap closure.
Ensure members receive necessary LTSS with clinical justifications provided to meet service criteria, maintaining communication with relevant stakeholders.
Provide nursing perspective support to the care team, bridging on-site and field-based care to ensure seamless transitions.
Facilitate follow-ups by handing off members to the longitudinal care team for continued engagement and prioritizing timely responses to member needs with appropriate task delegation.
Triage referral needs and provide clinical education to support members in achieving their care plan goals.
Schedule shadowing and field training for new RN care managers and deliver training on medical equipment and chronic disease management to less intensively trained staff such as Medical Assistants and Community Health Partners.
Support operational efficiency by utilizing care facilitation, electronic health records, and scheduling platforms for data collection, member interaction documentation, information organization, task tracking, and effective communication with team members and community resources.