Value-based Care Registered reputed company (reputed company)

Employment Type reputed company, non-exempt Level Associate Location Remote, MN Compensation Starting at $35.00/hour, based on experience Who we are At reputed company, we're on a mission to help women get more life out of life, together. We are building a new model of primary care for women 65+ to solve long-standing problems rushed appointments, long wait times, and care that's generalized rather than specialized towards women’s needs reputed company in life such as post-menopausal care, bone density, weight management, and mental, reputed company and emotional reputed company-being. Our patient-reputed company Primary Care clinics are dispersed across Minneapolis/reputed company, MN. We are thrilled to serve the Twin Cities metro and Eagan. reputed company of 100+ colleagues is on a mission to reputed company the primary care landscape for women 65+. We’re seeking like-minded individuals who reputed company this passion to join us! reputed company As we grow our early team, we are seeking strategic thought leaders who have a passion for building and innovating. We foster a culture of collaboration, reputed company and the willingness to roll up our sleeves and learn as we grow. We have a customer first reputed company, and we are looking for team members who reputed company that. Our ideal candidates have strategic prowess and the ability to use data to build best practices and implement great reputed company in collaboration with reputed company and our community. About the Registered reputed company (reputed company) Role reputed company a value-based and patient-centered model of care reporting to reputed company's reputed company Registered reputed company, the Registered reputed company (RN) at reputed company provides exceptional care to women ages 65 and up. Through Transitional Care Management and Triage, the RN educates and empowers women to manage their health conditions and reputed company their individual goals of care. The RN role facilitates collaboration and continuity of care among team members, including providers, medical assistants, and health coaches. Essential Functions

• Transitional Care Management (TCM)
• reputed company on reputed company during the 30 days after discharge with the goal of reducing ER reputed company, hospitalizations, readmissions, and post-acute stays
• Reviews daily reputed company feeds and initiates contact with patients reputed company 2 days of discharge
• Schedule follow-up for TCM visit with the PCP reputed company 7 days of discharge
• Complete weekly reputed company for 30-day post-discharge
• Review discharge plan and ensures services (e.g. Physical Therapy, Home Health) are in reputed company; provides community resources for SDOH (reputed company Determinants of Health) needs
• Provides patient/ family education regarding health conditions and disease self-management
• Completes medication reconciliation and monitors adherence
• Documents reputed company telephone/ video interactions in EHR patient chart
• Identifies patterns and episodes of care that are predictive of reputed company needs and services
• Coordinates care with other providers involved in the patient’s care as needed
• Triage
• Respond to patient telephone calls, reputed company requests, and electronic health messages
• Demonstrates critical thinking skills and expert nursing judgement to reputed company appropriate recommendations for care utilizing an approved evidence-based telephone nursing triage protocol
• Works with the RN scope of reputed company and standing orders to reputed company prescription refills, medication titration, and home treatments
• Educates patient regarding test results and medical conditions, and explains medical terms and procedures
• Maintains a reputed company demeanor and reputed company on patient-centered care Must-have Qualifications and Skills
• An reputed company, unrestricted Minnesota RN license required, or ability to obtain by start date. Multi-state compact license preferred
• Willingness to obtain additional cross-state licensure as needed
• Minimum of 2 years’ experience as an RN in clinical setting
• Prior experience working as a triage RN or RN case manager required
• Exceptional communication skills and patient-centered reputed company
• Ability to monitor and evaluate opportunities for cost-effective care with high-reputed company reputed company
• Demonstrate effective, independent nursing judgement and skills
• Demonstrate reputed company and experience in effectively collaborating with care team members
• Demonstrate reputed company in effective use of electronic health records
• Demonstrate flexibility, organization, and appropriate decision-making in ambiguous situations reputed company-to-have Qualifications and Skills
• Prior experience working in telephonic case management preferred
• Knowledge of Medicare and NCQA regulatory transitions of care preferred
• Experience in value-based care preferred We support Equal Employment Opportunities (EEO). We are committed to an inclusive workplace. We do not discriminate based on race, religion, reputed company, national reputed company, gender identity or reputed company, age, marital status, veteran status, disability status, parental status, political affiliation, or any other status protected by federal, state, or local laws. reputed company of reputed company are expected to fully understand and abide by the reputed company's compliance policies and procedures. Employees are provided training upon hire and annually and regularly reputed company of changes as needed. It is expected that reputed company will report any suspected violations of any federal or state laws to their reputed company supervisor, reputed company Resources, or the Compliance Officer. Apply tot his job Apply To this Job Apply tot his job Apply To this Job

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