Integrated Care Team 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 Field 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 Field RN, you will provide patient support both virtually via video, telephone, or text, along with in the home and community visits. 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. As a field RN you will be a patient advocate, ensuring the most vulnerable patients are supported, attended to, and enabled to live their best possible lives. As part of the Integrated Care Nursing Team you will provide support to our triage and transition of care nursing teams facilitating ongoing patient care 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, 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.
• 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 g