Field Registered Nurse Sr Community Care Jacksonville FL

About the position The Long-term Care and Assisted Living Optum Registered Nurse plays a crucial role in providing integrated care to patients in nursing homes and assisted living facilities. This position involves collaborating with interdisciplinary teams to ensure comprehensive care coordination, addressing both physical and mental health needs of patients. The RN will travel to various facilities within designated counties, working closely with providers and clinical managers to enhance patient outcomes and support the overall care journey. Responsibilities • Assist the provider/team with various care coordination activities in the nursing home. , • Assist the provider/team with benefit determination associated with Medicare part A, part B, and part D benefits. , • Collaborate with the primary Advanced Practice Clinician (APC) and nursing facility to identify and respond to patient changes in condition. , • Complete Decision Support Tool (DST), re-assess the patient, and perform other activities as delegated by the provider or Clinical Services Manager (CSM). , • Assist the provider/team with therapy coordination for members, including assessments and follow-up on requests. , • Perform interval check-ins on patient progress with the therapy department. , • Participate in facility-based therapy discussion meetings. , • Schedule and participate in family conferences, team meetings, and team case presentations. , • Assist in the coordination of training, tracking, and compliance with quality measures. , • Participate in the onboarding of new clinical staff under the direction of the CSM. , • Participate in facility partnership or Customer Relationship Management (CRM) meetings under the direction of the APC/CSM. , • Assist in coordinating CRM meetings and contribute to the discussions. , • Track LearnSource completion for team members and CSM. , • Create and conduct in-services for selected audiences. , • Document information and activities in the EMR. , • Assist providers in ensuring complete and accurate documentation and coding, medication reconciliation, nursing rounds, assessment, and patient documentation. , • Assist the team/providers in prioritizing advance care planning and initiating discussions. , • Collaborate with key stakeholders, providers, nursing homes, PCPs, families, and interdisciplinary care teams. , • Review charts and enter HEDIS/Quality information into the EMR, communicating gaps to the provider. , • Write verbal orders from the provider in compliance with state RN practice laws and nursing facility practices. , • Conduct goals of care conversations. , • Assist with patient care in the state of Washington, either face-to-face or telephonically. Requirements • Associate degree or higher in Nursing (RN). , • Current unrestricted Registered Nurse license in the state of Florida. , • Certified in Basic Life Support. , • Valid driver's license with access to reliable transportation for travel up to 100% to visit clients and/or patient sites. Nice-to-haves • For new RN graduates, proven ability to obtain an unrestricted Registered Nurse license in the state of Florida within 12 months of employment. , • 1+ years of experience in post-acute care, such as long-term care. , • 1+ years of experience working with the geriatric population. , • 1+ years of experience using electronic medical records. , • Bilingual English/Spanish. , • Proven ability to work with diverse care teams in various settings. , • Proven effective communication skills and time management. Benefits • Paid Time Off which accrues with the first pay period plus 8 Paid Holidays. , • Medical Plan options along with participation in a Health Spending Account or a Health Saving account. , • Dental, Vision, Life & AD&D Insurance along with Short-term disability and Long-Term Disability coverage. , • 401(k) Savings Plan, Employee Stock Purchase Plan. , • Education Reimbursement. , • Employee Discounts. , • Employee Assistance Program. , • Employee Referral Bonus Program. , • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.). Apply Job!