Field RN- At Home Care- Must reside in Philadelphia, PA

Field RN - Chronic Risk / AT Home Care Program



*Sign On Bonus Available!

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Field patient care role.

Primarily responsible for conducting in home visits, nursing assessments, patient triage, care coordination, and patient/family education for the members assigned to the provider.

Field RN supports providers and their respective patients, and also addresses client-facing needs per POD/market.

Perform home visits with patients enrolled in At Home Care Chronic Risk Program and/or Advanced Care program (ACP)


* Provides up-to-date health care advice/education regarding health promotion, illness prevention, and management of disease utilizing nursing assessment data, patient, family, and approved At Home Care Triage protocol.

Considers the physical, cultural, psychosocial, spiritual, age-specific and educational needs of the patient.


* Systematically assesses patients' actual or potential health care needs, prioritizes their urgency and uses creative and effective problem solving/decision making while recommending an appropriate disposition per clinician and protocol direction.


* Documents nursing assessment, planning, implementation in the electronic health record.

Documentation is timely and in accordance with policy.

Evaluates the patients' and family's response to teaching.

Documentation includes presenting problem, nursing assessment interventions, education and patients' response to interventions/treatments and education.


* Makes follow-up telephone calls to patients and referrals as appropriate.


* Provide telephonic nursing assessment and triage supported by triage protocols.

This includes, timely and accurate triage documentation, escalation, and follow up


* Initiate medication changes and other orders, as directed by provider in response to a triage call.

Health Literacy Improvement



* Improves Health literacy and coaches consumers on chronic conditions including disease process and trajectory, medication education including possible side effects, plan of care, and individualized care goals management in a culturally sensitive and acceptable manner for the patient or caregiver.


* Identifies problems or gaps in care, and offers opportunity for intervention


* Coordinates services and referrals to health programs, and participates in patient education and outreach tied to HEDIS initiatives


* Works to improve access to care, and works as part of the team to manage heath care cost and utilization

Provider Support


* Completes telephonic nursing assessments including social determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider


* Assists with organizing and running a 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 he...