RN Coordinator- At Home Care- Hybrid- Philadelphia, PA

About the position Responsibilities • Be the point of contact for all aspects of the member in regard to their appointments, care, and overall health. • Act as the liaison between the providers and their patient panel, directing and delegating tasks to team members. • Educate patients about their care options and make specific recommendations based on their goals. • Review paperwork for patients to ensure it meets all requirements. • Explain test results, diagnoses and other medical outcomes. • Cover any additional triage and transition of care for patients as needed. • Improve health literacy and coach patients on chronic conditions including disease process and trajectory, medication education including possible side effects, plan of care, and individualized care goals management. • Identify problems or gaps in care and offer opportunity for intervention. • Coordinate services and referrals to health programs and participate in patient education and outreach tied to HEDIS initiatives. • Work to improve access to care and manage healthcare costs and utilization. • Complete telephonic nursing assessments including social determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider. • Assist with organizing and running chronic care and/or interdisciplinary care team rounds where high risk patients and care plans are identified. • Participate using a team approach to create a care plan for the patient. • Maintain and update spreadsheets and documents provided by health plan to prep weekly rounds of documentation. • Participate in weekly care coordination with health plan case management as directed by market needs. • Manage referral coordination and tracking of hospice consults within 24 hrs. of order placement. • Obtain Pre Authorization for all CT, MRI, Echo's ordered by providers. • Serve as a guide in their POD for all escalated orders and results as clinically appropriate. • Assess and triage immediate health concerns transferred to nursing team by clinical support staff. • Provide telephonic nursing assessment and triage supported by triage protocols. • Initiate medication changes and other orders, as directed by provider in response to a triage call. • Monitor daily discharge list and develop a plan to schedule transition of care visits within the allotted timeframe. • Complete telephonic post-discharge hospital visits and ask pertinent discharge triage questions and complete medication reconciliation. • Document all findings and make appropriate referrals to social work, pharmacy, case management and engagement. Requirements • Active, unrestricted RN license in all states we provide services. • Ability to obtain compact license and/or additional state licensure as needed. • 3+ years of experience as a Registered Nurse. • Proficient level of experience with Microsoft Office applications, and strong technical aptitude. • EMR experience and proficiency. • BSN or ADN degree. Nice-to-haves • Previous experience working with the geriatric population/ chronic condition experience. • Home Health experience. • Triage experience. • Case management experience. • Previous customer service experience. • Previous experience in a telephonic role. • Highly organized, self-directed worker with an ability to function in high volume environment. • Strong verbal and written communication skills. • Prior clinical experience in palliative care, end of life, hospice, oncology, ICU, geriatrics is preferred. • Knowledge of STARS and Hedis metrics a plus. Benefits • Smoking cessation program Apply tot his job Apply To this Job