Registered Nurse-In Home Primary Care- Hybrid- Houston, TX

The RN serves as the key contact point for the patient to coordinate and streamline all services offered within Evernorth. The RN will educate the patient on healthcare options, provide patient education and answer questions as they arise. The RN will be compassionate and positive who inspires confidences in the patients they work with. The RN will work hand in hand with patients, other staff and providers to help answer any questions they have regarding schedules, appointments, orders, consults, etc. The RN will be responsible for knowing where to look for all of the members information and directing and delegating tasks to team members as needed.

Key Responsibilities

Core Responsibilities

1. Be the point of contact for all aspects of the member in regard to their appointments, care, and overall health.

2. Act as the liaison between the providers and their patient panel, directing and delegating tasks to team members

3. Educate patients about their care options and make specific recommendations based on their goals

4. Review paperwork for patients to ensure it meets all requirements

5. Explain test results, diagnoses and other medical outcomes

6. Cover triage and transition of care for patients

Health Literacy Improvement
1. Improves health literacy and coaches patients on chronic conditions including disease process and trajectory, medication education including possible side effects, plan of care, and individualized care goals management in a culturally sensitive and acceptable manner for the patient or caregiver.
2. Identifies problems or gaps in care and offers opportunity for intervention
3. Coordinates services and referrals to health programs and participates in patient education and outreach tied to HEDIS initiatives
4. Works to improve access to care and works as part of the team to manage heath care cost and utilization

Provider Support
1. Completes telephonic nursing assessments including social determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider
2. Assists with organizing and running a chronic care and/or interdisciplinary care team rounds where high risk patients and care plans are identified
3. Participate using a team approach to create a care plan for the patient
4. Maintain and update spreadsheets and documents provided by health plan to prep weekly rounds of documentation
 

Post-Acute Management and Coordination
1. Participation in weekly care coordination with health plan case management as directed by market needs
2.  Referral Management Care Coordination and tracking of hospice consults within 24 hrs. of order placement

Diagnostics and Lab Result Management
1. Obtain Pre Authorization for all CT, MRI, Echo’s ordered by providers  and schedule patient

2. Serves as a guide in their assigned market for all escalated orders and results as clinically appropriate
 

Additional Responsibilities:

Nursing Triage
1. Assess and triage immediate health concerns transferred to nursing team by clinical support staff.
2. Provide telephonic nursing assessment and triage supported by triage protocols. This includes, timely and accurate triage documentation, escalation, and follow up
3. Initiate medication changes and other orders, as directed by provider in response to a triage call.

Transition of Care
1. Monitors daily discharge list and develops a plan to schedule transition of care visits within the allotted timeframe

2. Complete telephonic post-discharge hospital visits and ask pertinent discharge triage questions and complete medication reconciliation
3. Document all findings and make appropriate referrals to social work, pharmacy, case management and engagement

Other telephonic patient care and provider support duties as assigned

Competencies:
• Communicates Effectively – Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences

• Manages Ambiguity- Operating effectively, even when things are not certain or the way forward is not clear

• Courage – Stepping up to address difficult issues, saying what needs to be said

• Manages Complexity – Making sense of complex, high quantity, and sometimes contradictory information to effectively solve problems

• Demonstrates Self-Awareness-  using a combination of feedback and reflection to gain productive insight into personal strengths and weaknesses

• Situational Adaptability- Adapting approach and demeanor in real time to match the shift in demands of different situations

• Collaborates – Building partnerships and working collaboratively with others to meet shared objecti