Registered Nurse -Post Acute Care Initiatives Hybrid/Float RN Onsite NYC

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

A Brief Overview

This is a unique hybrid position that will support the an external provider team as a Float Registered Nurse. This position will help to help cover for the team if and when needed and for all the three initiatives – Skilled Nursing Facility, Home Health Care and Inpatient Strategy. Position requires cross training to understand the goals and operational workflows for the three initiatives mentioned above.

Approximately 70% of the time is remote/home-based work, with 30% of the time being onsite.
Working schedule is Monday-Friday; will work between 8am - 5pm EST. No nights, no weekends, no on call and no holidays.

What you will do

Home Health Care Initiative:

• Uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria for the most appropriate treatment, care or services for patients.
• Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment.
• Through broad knowledge of clinical care the Home Health Utilization RN evaluates, predicts, and facilitates the trajectory of patient care.
• Care Coordination and facilitation for community-based home health referrals or linkage to alternative community resources to obtain appropriate care. 
• Will identify and coordinate appropriate community-based services in lieu of home health, when appropriate.
• Engages with the patient/caregiver telephonically using tools such as standard assessments, patient care plans, and documents all interactions in the EHP.
• Home Health Utilization RN will communicate patient plan of care and discharge status with the Primary Care Physician and/or Specialist.
• Provides clinical expertise and helping to clarify referral source directives and community-based linkage.
• Participates in performance, operational and quality improvement activities and ensures the collection of data for improvement analysis and prepares reports as requested.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
• Responsible for performing other duties as requested by Associate Director, Post-Acute Care and MSHP Leadership

Population Health Transitional Care Coordination - Inpatient Strategy:

• Responsible for reviewing and assessing MSHP aligned acute care patients
• Establishes, revises, and evaluates a plan of care which is appropriate to problems identified and involves the patient/family and interdisciplinary team
• Provides for continuity of care by participating in discharge planning with patients, families and inpatient/outpatient team as appropriate, providing home instructions to patients and caregivers, recommending and or providing equipment/home modifications, and recommending appropriate follow-up care if needed. In instance that sub-acute rehabilitation is necessary, educates patient and caregiver on preferred provider network
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render determination/recommendation along the continuum of care
• Responsible for communicating with interdisciplinary teams
• Attend and participate in daily rounds with the interdisciplinary team, reporting any concerns and recommendations for the MSHP aligned patients
• Responsible for documentation
• Responsible for performing other duties as requested by Population Health Manager, Associate Director, Post-Acute Care and MSHP Leadership

Population Health Post-Acute Care Clinical Coordinator - Skilled Nursing Facility Initiative:

Responsible for reviewing and evaluating post-acute care services provided to MSHP population

• Identify on a daily basis, MSHP lives that are being serviced in SNFs