Integrated Care Team Registered Nurse

Summary

Join Accompany Health in giving low-income patients with complex needs the dignified, high-quality care they deserve. As an Integrated Care Team Field RN, you will provide patient support virtually and in-home, driving pathways for chronic disease management, and ensuring appropriate creation of care plans.

Responsibilities

• Driving pathways for chronic disease management (e.g. CHF, COPD, CKD/ESRD, and diabetes) for a panel of patients, including performing clinical assessments, providing patient education and coaching, ensuring closure of quality gaps, connecting and navigating to appropriate services, and supporting remote monitoring
• Ensuring appropriate creation of care plans for patients qualifying for pathways and quarterback appropriate coordination, patient coaching, and follow through on the plan
• Leading case conferences for your patient panel and ensuring appropriate documentation on changes to care plans and progress
• Providing virtual, telephonic, and in-home or community care for patients with poorly controlled chronic or acute illnesses
• Performing nursing interventions such as patient clinical assessments, administering vaccines and medications under the supervision of a provider or MD, performing wound care, and facilitating ongoing chronic disease management and patient education
• Establishing and fostering trusting relationships with your patients and ensuring that care is appropriately aligned with their goals and values
• Supporting nursing teammates in telephonic triage and transition of care through ongoing team collaboration and assistance as needed
• Participating in multi-disciplinary case conferences and clinical rounds to ensure holistic and appropriate care for patients
• Collaborating with external providers and community-based organizations to advocate for patient care aligned with their goals
• Providing feedback on program design and workflows to ensure we are providing the best patient care possible
• Modeling excellent communication, documentation, efficiency, and critical thinking skills to the interdisciplinary team