Overview

The Post-Acute Care program helps to reduce hospital readmissions of patients and has aspects of education and coaching to assist patient’s transition home after a hospital stay. The program works directly with patient treatment plans, facilitates in home health care services to accomplish the treatment plan, patient goals and patient education/coaching along with adherence/compliance monitoring.

This remote position utilizes clinical expertise to manage assigned Post-Acute Care patients’ transition from acute care setting to the home setting through telephonic outreach to provide education, coaching and care coordination to accomplish the goals of the Post-Acute Care Program. The Nurse Coach engages Post-Acute Care patients in the program and administers initial, update, and discharge assessments in an effort to prevent readmissions. This position works closely with the Post-Acute Care patient home health agency nurse, and physicians where applicable, to facilitate education and adherence to establish health care goals and care plan. Participates in performance and operational improvement activities. Works under moderate supervision.

Responsibilities

In this Job, you will:

• Manage the transition of assigned Post-Acute Care patients from acute care setting to the home setting utilizing telephonic outreach and teaching methods combined with facilitating in home health care services to accomplish the goals of the Post-Acute Care Program.
• Work in an inbound call queue and outbound patient telephonic engagement model.
• Educate, coach and influence patient and caregiver behavior to achieve care plan goals.
• Engage Post-Acute Care patient in the program and performs assessments that directly tie to reducing readmissions. These include but are not limited to: Educating members regarding their Discharge Instructions, ensuring a follow up PCP appointment is in place, medication reconciliation, educating on the signs and symptoms of their condition, referral to community resources and caregiver support.
• Document all interactions, guidance and interventions in CareCentrix applications ensuring documentation guidelines are maintained. Communicate customer service/provider issues to supervisor for logging and resolution.
• Communicate customer service/provider issues to supervisor for logging and resolution
• Participate in and contributes to ongoing case rounds and quality assessment/improvement activities.
• Participate in implementing / maintaining operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
• Participate in special projects and performs other duties as assigned.
• Schedule Tuesday-Saturday each week and daily hours 8 am or 9 am start – 5 pm or 6 pm ET.

This is the job for you if:

• You possess excellent negotiation, communication, problem solving and decision making skills also required.
• You have excellent organizational and interpersonal skills, be detail oriented, and able to manage multiple tasks in a fast paced environment.
• You possess basic knowledge of MS Outlook and Excel documents and can easily learn to navigate in an electronic patient medical record.

Qualifications

You should get in touch if:

• You have an Associate's, bachelor’s degree, or higher in Nursing and an unrestricted RN licensure in the state(s) of practice. (Required)
• You are an RN with a minimum of 5 years' experience.
• You hold or can obtain a Compact/Multi-State RN License (preferred) OR have a single state license with the ability to obtain additional licensures as requested.
• You are experienced as a Nurse Coach or Case Management Nurse (Preferred)

What we offer:

• Full range of benefits including Health, Dental and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.
• Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more.
• Advancement opportunities, professional skills training, and tuition Reimbursement
• Great culture with a sense of community.

CareCentrix maintains a drug-free workplace

#IDCC

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law

CareCentrix accepts applications on an ongoing basis until a candidate is identified.