Candidates must live in Puerto Rico

Job Title: Field Registered Nurse (RN)
Posting Options: Registered Nurse, Field RN
Status: Exempt
Reports To: Clinical Service Manager
Department: Care Delivery
Date: February 2022
Location: Local Market Region

About Emcara Health Value-Based National Medical Group

Our mission is simple leading the effort to reimagine how health care is delivered for our nations most vulnerable seniors and adults. Improving the lives of those most in need guides everything we do, and we believe that as we continue to stay focused on that compass heading we will increasingly be recognized as Americas leading national medical group providing house calls for vulnerable populations.

We have brought the same focus to the experience of our own team members as we have to our patients, and through the prioritization of Joy In Work have made the Quadruple Aim in health care delivery our clinical true north.

Emcara core care teams are multi-disciplinary and include Community Health Workers (CHW), Registered Nurses (RN), Advanced Practice Providers (APP- NP/PA), and complex care physicians (CCP), among other care coordination and specialized resources such as palliative care and behavioral health clinicians, Clinical Pharmacists, Pharmacy Technicians, Social Workers (SW), Physical Therapists, and Registered Dieticians (RD).

Our care teams understand that vulnerable populations require a new brand of care to live their healthiest life possible- home-based advanced primary care. Advanced primary care is comprehensive, and includes medical, behavioral, and social care, and can be delivered either as the PCP of record, or in collaboration with patient PCPs to deliver an added layer of support.

Value-based payment methodologies allow our physicians and APPs both the time they need to restore the clinician-patient relationship, as well as ensure the patient and clinician are surrounded by a care team that is able to address all of their care needs, especially their behavioral and social needs.

Role Summary:

Reporting to their local Clinical Service Manager (CSM), the Field RN will be based in the indicated market. With responsibility for supporting the patient panel attributed to their care team pod, in partnership with their Advanced Practice Provider and Community Health Worker this individual will have specific responsibility for both direct care delivery and care coordination.

This is a get into the weeds, build-it and make it better kind of job, requiring high energy, deep engagement, and a strong work ethic. This individual understands the necessity of offering differentiated treatment models for vulnerable populations across a broad chronic illness spectrum.

Role Responsibilities:

• Completes intake/enrollment visits with eligible PopHealthCare participants, followed by telephonic nursing care calls and/or in-home assessments for an assigned caseload

• Adjusts visit frequency and schedule as needed to ensure patient stability and safety at home

• Maintains regular contact and communication among the care team, patient, community providers and other authorized contacts or caregivers as indicated

• Facilitates Advance Care Planning (ACP) working with the care team and identifies surrogate decision maker (MPOA, Health Proxy et al.)

• Collaborates with the care team in the development of an integrated plan of care that identifies key patient problems, goals of care, barriers to meeting goals, interventions, and patient self-management activities

• Shares plan with the patient and/or authorized contacts

• Reviews and updates plan of care at least monthly and as needed with significant patient status changes

• Implements interventions identified to meet care goals

• Modifies plan of care as appropriate

• Manages patients care as appropriate including:

• Provides effective patient education leveraging the spirit of Motivational Interviewing, as well as the Teach-Back technique

• Addresses recommended preventive and quality measures; acts to sustain progress achieved or to close known care gaps

• Monitors chronic conditions to minimize exacerbations

• Identifies and assesses chronic exacerbations and acute changes of condition and refers to care team as appropriate for diagnosis and treatment

• Facilitates medication reviews, reconciliations, and education to support care plan adherence

• Proactive care coordination for assigned caseload

• Assists with implementation of standing and other orders as necessary

• Receives inbound calls from members regarding urgent/acute needs and communicates needs to CARE TEAM as appropriate

• Makes care calls and actively manages lost-to-service processes as appropriate

• Documents all patient encounters (in-home and telephonic) per documentation standards

• Participates in Multidisciplinary Team Meetings and clinical case conferences as required

• Collaborations with Behavioral Health Care Manager in regions as is relevant

• Coordinates and communicates with health plan case managers, facility staff and others involved in patient care

• Communication Skills, Knowledge of Motivational Interviewing

• Must have a strong desire to build close relationships with all members of the field and regional teams.

• Must be committed to working in a collaborative relationship with the members primary care provider.

• Excellent time management, organizational skills, and strong communication is a must.

• Other Duties as assigned

Role Qualifications:

We are searching for a special breed of health care professional who embodies the following qualities and characteristics: heart and commitment to serve vulnerable populations, passion and perseverance to achieve long-term goals (a.k.a. grit), team-based and social determinants of health orientation, and embrace change in a rapidly evolving health care delivery system. Flexible and dynamic, this self-starting individual will be a creative problem solver with a proven track record of successful implementation of innovate health care delivery solutions. They must possess excellent time management and organizational skills, with the ability to prioritize and multi-task. Additional qualifications include-

• Holds active, unencumbered license in state of practice

• Two or more years of practice experience required; preferably in the care of chronically ill adult patients

• Two or more years of home health or case management experience preferred

• Triage and transition of care experience preferred

• Strong organizational skills and multitasking abilities

• Effective problem solving and appropriate application of clinical knowledge

• Effective communication and interpersonal skills

• Contributes positively among the care team and actively promotes teamwork

• Current Certification in AHA or ARC Basic Life Support for health care providers required for employment

• Ability to navigate and use an electronic health record for documentation, and working knowledge of computers and ability to document effectively and efficiently in an electronic health record system

• Drivers license requirements: licensed for a minimum of 3 years without restrictions; no DUI or other felony driving conviction in the past 7 years

• “Preferred that candidate has active Department of Health certification for vaccine administration”

  
  

PopHealthCare is an equal opportunity/equal access employer fully committed to achieving a diverse workforce.