Transitional Care Management Registered Nurse

American Addiction Centers • Mint Hill, NC

4d • $41 - $62 • Remote

About The Position

This is an exempt, full-time, remote-from-home position requiring the nurse to live within the Greater Charlotte area in NC and have high-speed internet. The role involves managing a caseload of patients, primarily through telephonic and virtual means, to improve outcomes for patients with targeted vulnerabilities. The nurse will collaborate with various internal and external partners to ensure seamless transitions of care, facilitate communication, and identify/resolve barriers to care. A key aspect of the role is utilizing evidence-based approaches to increase patient and family activation and engagement in their own care, and partnering with patients to set SMART goals. The position requires the ability to demonstrate knowledge and skills appropriate for the age of the patients served, including understanding growth and development principles. Administrative tasks, such as equipment allocation and onboarding, may also be assigned.

Requirements

• Registered Nurse license issued by the state(s) in which the teammate and the department provide care. May require additional licensing for non-compact state.
• Bachelor of Science in Nursing.
• At least 5 years of nursing experience caring for patients within the population targeted by the Transitional Care Management program.
• At least five years of experience in a formal or informal leadership role.
• Knowledgeable in best practice for targeted population, which are set forth by a relevant professional organization and/or substantial body of evidence.
• Knowledgeable in technology platform that hiring department utilizes.
• Must be self-directed with the ability to work well independently and within a team environment while recognizing and meeting the individual needs of external and internal partners/customers.
• Ability to demonstrate excellent oral, written and interpersonal skills.
• Ability to demonstrate critical thinking, problem solving and excellent organizational skills.
• Ability to work productively and effectively in a complex environment that includes multiple changing priorities.
• Demonstrated ability to work well with physicians and other healthcare professionals in a direct and positive manner.
• Proficient computer/Microsoft-suite skills and previous Epic EMR experience.
• Ability to handle multiple responsibilities.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.
• Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures.
• Must be able to lift up to 20 lbs. and use repetitive activities of the fingers, hands, and wrists.
• Must be able to sit, stand, walk, lift, squat, bend, and reach above shoulders and twist frequently during work shift.
• Must have functional sight and hearing.

Nice To Haves

• Master’s degree in nursing.
• Certification in a domain relevant to targeted patient population.

Responsibilities

• Collaboratively develop policies, procedures, protocols, and/or standing orders to support top-of-license nursing work to improve outcomes for patients with targeted vulnerabilities.
• Advise operational leaders on population identification, workflows, and optimization of patient outcomes by reviewing and synthesizing department data, published literature, legal statutes, professional practice standards, and industry norms.
• Assist Managers and Program Coordinators in conducting audits to ensure the highest level of quality, safety, adherence to standards, and performance in care delivery.
• Orientate new staff and support development of existing staff in collaboration with Manager, NPDS, and preceptors.
• Engage in advocacy activities within and/or outside of the healthcare system to address internal and external policies or workflows that limit patients’ ability to access and receive best-practice support, services, or resources.
• Maintain a high level of up-to-date knowledge in area of expertise by identifying and engaging in learning opportunities.
• Participate in dissemination of program outcomes and findings to enhance internal and external knowledge.
• Analyze readmission and program data, identify trends, and collaborate with internal/external teams to develop tactics and implement strategies to reduce readmissions.
• Monitor the impact of strategies and make data-driven adjustments for continuous improvement.
• Outreach to and manage a caseload of patients identified through referrals/consults and/or population stratification algorithms.
• Interact with patients primarily through telephonic and/or virtual means.
• Facilitate communications among patient/family, multidisciplinary team, medical management team, community resources and other disciplines to anticipate, identify, evaluate, and act to resolve any potential barriers and constraints to delivery of care in a timely manner.
• Understand and interpret multiple contracts and contractual obligations to enable the care management team to achieve maximum clinical and financial outcomes.
• Collaborate with the patient/family and inter-professional team to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services.
• Use evidenced-based approaches to increase patient and family activation and engagement in their own care.
• Partner with patients and family to develop SMART goals.
• Assist in the development, procurement, and adoption of patient self-management educational resources.
• Identify potential barriers to learning and/or to the optimal delivery of care.
• Report abnormal findings to the responsible provider/care team and collaborate to develop a plan.
• Independently manage CM caseload according to department expectations.
• Ensure timely completion of tasks and documentation related to regulatory and contractual requirements.
• Partner with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care.
• Anticipate the needs of the patient, recognize and respond to changes in a patient’s status and determine priorities of patient care based on essential patient needs.
• Coordinate patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) and other members of the patient care team to ensure smooth transitions of care.
• Coordinate referrals to other internal AAH departments and/or external community resources as necessary.
• Demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.
• Partner with departmental manager/leaders to complete administrative tasks such as equipment allocation, payroll, onboarding activities, and other duties as assigned.

Benefits

• Comprehensive suite of Total Rewards: benefits and well-being programs
• Competitive compensation
• Generous retirement offerings
• Programs that invest in your career development
• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

What This Job Offers

• Job Type: Full-time
• Career Level: Senior