The Nurse is responsible for providing continuing health coordination and disease education to the senior population who has chronic conditions as part of a multidisciplinary team. In this unique role you will have opportunity to incorporate the social and emotional well-being of the Individual to personalize their care experience while building a relationship through collaboration with members, caregivers, and colleagues. Work assignments for the Nurse are varied and frequently require interpretation and independent determination of the appropriate courses of action.
- Utilize clinical judgement to design, implement, and monitor evidence-based actionable care plans within a disease management/care coordination program that are aligned with the Member’s goals in collaboration with caregivers, the Team, primary care providers, and other members of the health care team.
- Timely completion of initial and ongoing assessments as needed.
- Facilitation of member and caregiver access to community resources.
- Works in conjunction with a Care Team to be the liaison between the Member and barriers to their whole health.
- Responsibilities include but are not limited to:
- Implementation of assessment tools to identify health risks, documenting progress towards reducing the Member’s health/social/emotional risk, and discussing the findings of the case with Care team members to provide optimal whole health care.
- Assist Members in identifying, measuring, tracking, and achieving whole health goals.
- Engaging with Members in their home environment as needed to develop and collaborate on care plans to increase their whole health experience and help prevent unnecessary hospitalizations.
- Empower Members to guide their physical, environmental, and psycho-social health issues with their Care team.
- Collaborate with and establish strong personal relationships with Members, partners, providers, and the team.
- Travel within the local region and occasional interstate travel may be required.
- Provision of guided group discussions/educational classes for Members within an Edge Community Center. Actively participates in educating care team members, including PCPs and support staff, on Care & Disease Management principles. Education including but not limited to: the development of assessment and intervention/treatment options as appropriate to the team member’s scope.
- May serve as the client representative on Client level Care & Disease Management planning and program development forums and work groups.
- Ability and willingness to be an instrumental part of a growing team by joining work groups to assist and guide the development of the Edge team in South Carolina.
- Graduation from an accredited School of Nursing
- Current RN licensure, with no restrictions, in the State of South Carolina
- Must have a minimum of 2 years of clinical experience
- Experience working with either geriatric, chronically ill and/or functionally challenged populations
- Registered Nurse with 2 years of experience of in home case/care management
- Confidence and comfort in learning new technology
- Knowledge of community health and social service agencies and additional community resources
- Ability to travel to member’s residence within 30 to 40 miles
- This role is a part of Client’s Driver Safety program and therefore requires and individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,00 limits.
- Must have a separate room with a locked door that can be used as a home office to ensure continuous privacy while you work
- Must have accessibility to high speed DSL or Cable modem for a home office
- This role is considered patient facing and is part of Client’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB
- Valid driver’s license, car insurance, and access to a reliable automobile
- Ambulatory care experience preferred
- Complex care management/Disease Management experience
- Utilization Management experience
- Experience with health promotion, coaching and wellness