Registered Nurse- In Home Primary Care-Hybird-Philadelphia, PA

About the position

The RN Coordinator serves as the primary contact for patients within Evernorth Health Services, focusing on coordinating and streamlining healthcare services. This role involves educating patients about their healthcare options, providing support, and ensuring effective communication between patients and providers. The RN Coordinator is responsible for managing patient care, addressing inquiries, and facilitating access to necessary services, all while promoting health literacy and improving patient outcomes.

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 and medication education.
• Identify problems or gaps in care and offer opportunities for intervention.
• Coordinate services and referrals to health programs and participate in patient education tied to HEDIS initiatives.
• Complete telephonic nursing assessments including social determinants of health screenings and triage.
• Assist with organizing and running chronic care and interdisciplinary care team rounds.
• Participate in creating a care plan for the patient using a team approach.
• Maintain and update spreadsheets and documents for weekly rounds of documentation.
• Participate in weekly care coordination with health plan case management.
• Manage referral tracking and hospice consults within 24 hours of order placement.
• Obtain pre-authorization for diagnostic tests ordered by providers.
• Guide escalated orders and results as clinically appropriate.
• Assess and triage immediate health concerns transferred to nursing team.
• Provide telephonic nursing assessment and triage supported by protocols.
• Initiate medication changes and other orders as directed by provider.
• Monitor daily discharge lists and develop plans for transition of care visits.
• Complete telephonic post-discharge hospital visits and medication reconciliation.

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 or chronic conditions.
• Home Health experience.
• Triage experience.
• Case management experience.
• Previous customer service experience.
• Previous experience in a telephonic role.
• Highly organized, self-directed worker with the ability to function in a 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 is a plus.

Benefits

• Medical insurance
• Vision insurance
• Dental insurance
• Well-being and behavioral health programs
• 401(k) with company match
• Company paid life insurance
• Tuition reimbursement
• Minimum of 18 days of paid time off per year
• Paid holidays