Home Health Care RN

Accompany Health is on a mission to give low-income patients with complex needs the dignified, high-quality care they deserve but rarely receive. A primary, behavioral, and social care provider, Accompany Health walks alongside patients for their entire care journey, offering at-home and virtual care, as well as 24/7 support. Partnering with innovative payors, Accompany Health is powered by remarkable care teams, elegant technology, and a commitment to evidence-based practice. 
We build long-term relationships with our patients so they know, without question, that our team is here for them day or night, year after year. We focus on the health outcomes most important to our patients to make it clear that they lead the way.
To achieve our mission, we collaborate with community-based organizations, local providers, and health plans. Led by our empathetic care teams, guided by proven care models, and powered by our own technology, we deliver a level of service that our communities rightfully deserve but rarely receive. 
While our headquarters is in Bethesda, MD, our teams are distributed across the country.  If you’re eager to make a tangible difference in people’s lives, to help correct long-standing disparities in health care, join us. 
About the role:
Integrated Care Team RNs are a key part of our Integrated Care Teams, which also include Physicians, Advanced Practice Clinicians, Community Health Workers, Patient Experience Navigators, RNs, Social Workers, Behavioral Health Clinicians, Psychiatrists, and Pharmacists. Together this team is responsible for providing and coordinating holistic, patient-centered care for an intimate panel of patients with complex medical, behavioral health, and social needs. 
As an Integrated Care Team RN, you will care for patients primarily virtually via video, telephone, or text, but also in the home and community as needed. You will drive and quarterback pathways for chronic disease management (e.g. diabetes, CHF, COPD, CKD/ESRD) for a panel of patients to help empower patient and caregiver self-management. You will also support the Integrated Care Team by performing clinical triage for our patients and responding with compassion and empathy while connecting them with appropriate care and resources that can keep them safely at home and out of the hospital when possible.

Responsibilities will include:

• 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 and follow through on the plan.
• Leading case conferences for your patient panel and ensure appropriate documentation on changes to care plans and progress.
• Performing clinical triage for inbound outreach from our patients and ensure the highest level of patient experience, safety, and connection to appropriate resources that can keep them safely at home and out of the emergency department/hospital when possible.
• Caring for patients primarily virtually via video, telephone, or text but also in the home and community, including performing patient clinical assessments, administering vaccines and medications, performing wound care. 
• Establishing and fostering trusting relationships with your patients and ensuring that care is appropriately aligned with their goals and values. 
• Participating in multi-disciplinary case conferences and clinical rounds to ensure holistic and appropriate care for patients.
• Providing formal and informal coaching and education to other clinical and non-clinical team members about chronic disease management and care. 
• 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.
• Ensuring timely and appropriate documentation.
• Roles and responsibilities may evolve as our care model develops. 

What makes you a fit for the team:

• Passionate about caring for complex, historically underserved patients with co-occurring chronic and behavioral health conditions in an integrated, multi-disciplinary model anchored in home-based and tech-enabled virtual care.
• Committed to providing the highest quality, outstanding clinical care to all patients, regardless of their needs.
• Consistently go the extra mile to ensure that our patients have the best healthcare experience possible.
• Excited to be a part of and contribute to the development of a rapidly evolving, innovative care mod