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Description
CARE TEAM NURSE

Upward Health is a home-based medical group specializing in primary medical and behavioral care for individuals with complex needs. We serve patients throughout their communities, and we diagnose, treat, and prescribe anywhere our patients call home. We reduce barriers to care such as lengthy delays due to scheduling. We see patients when they need us, for as much time as they need, bringing care to them. Beyond medical supports, we also assist our patients with challenges that may affect their health, such as food insecurity, social isolation, housing needs, transportation and more. It is no wonder 98% of patients report being fully satisfied with Upward Health!

Upward Health provides technology-enabled, integrated, and coordinated care delivery services that improve outcomes and reduce costs for patients with severe behavioral health diagnoses and co-morbid, chronic physical conditions. We are not your typical medical practice. At Upward Health, we see every day as an opportunity to make a difference in our patients' lives. We could tell you about our outcomes and patient satisfaction ratings. We could tell you about our commitment to our mission. Or you could join us and experience it all for yourself.

WHY IS THIS ROLE CRITICAL?

The Care Team Pod is a multidisciplinary team of licensed and unlicensed staff who provide direct support and care to Upward Health’s patients. The Care Team Pod is comprised of a diverse team that may include medical providers, nurse practitioners, registered nurses, licensed social workers, pharmacists, therapists, and care specialists. This team works within the community and in the patients’ homes or meet in agreed upon locations in the community. The Care Team Nurse is responsible for the direct care of an assigned cohort of high-risk patients, as well as the development, implementation and ongoing monitoring of care plans and outcomes for those patients. This role will demonstrate a commitment to effective and efficient care leading to high quality outcomes, while managing the total cost of care. The focus is to deliver care in the home, or the most optimal level of safe and effective site of care.

The Care Team Nurse acts as a liaison between patients, their families, doctors, and ancillary health care providers ensuring the patient, family and caregivers understand the care plan and can progress towards self-care wherever possible. The Care Team Nurse will serve in a direct care and patient advocacy role and will ensure interdisciplinary care is optimized toward targeted outcomes. The Care Team Nurse works directly with the patient in the field, i.e., member's home, provider's office, hospitals, etc., while collaborating with the Clinical Operations team to assess, plan, implement, coordinate, monitor, and evaluate services and outcomes to maximize the health of the patient. For some patients, the Care Team Nurse implements chronic care management, complex chronic care management, and/or intensive case management and care coordination efforts to support and guide the patient through their journey within the healthcare ecosystem of providers, hospitals, outpatient services, etc. In collaboration with the Care Transitions Nurse who is monitoring for Remote Patient Monitoring (RPM) alerts, the Care Team Nurse will take immediate action for abnormal or out-of-range patient results.

KEY RESPONSIBILITIES

Assess, evaluate, and provide for the ongoing monitoring of patient care coordination and delivery that results in optimized quality, clinical and financial outcomes
Complete comprehensive assessments and develops care plans utilizing clinical expertise to evaluate the patients need for Upward Health and additional services
Develop a relationship of safety and trust with transparent communication between the patient, caregivers, and the care team
Identify, acknowledge, and advocate for the needs of the patient
Build a patient-centric care plan and environment that incorporates the needs of the patient
Review the patient diagnoses and facilitate the coordination of treatment plans of the PCP, specialists, and interdisciplinary care team – Attend Interdisciplinary Team (IDT) rounds
Evaluate patient outcomes with respect to the medical record, patient and family history and available healthcare utilization information
Continuously monitor and update care plans and coordinate care across providers
Educate patients and families about treatment plans and options
Accurately document and submit medical documentation
Maintain knowledge of diagnoses, signs and symptoms of disease, standard therapy protocols derived from evidence-based outcomes, medications, and warning signs of non-optimal patient outcomes
Provide guidance and support to patients and families inclusive of community-based support programs
Review results from medical tests (lab, imaging, etc.) and ensure visibility across all care providers including escalation of abnormal or out-of-range findings
Implement physician orders – ensuring a linkage between all care providers throughout a patient’s episodes of care
Communicate patient progress by conducting regular interdisciplinary meetings and evaluations, disseminating results and obstacles to the healthcare team and family
Function as a resource for non-clinical staff including first point of contact for patient triage and with escalation to the provider(s) as needed
Coordinate community resources, with emphasis on medical, behavioral, and social services
Apply case management standards, maintains HIPAA standards and confidentiality of protected health information, and reports critical incidents and information regarding quality-of-care issues
Meet with patients in their homes, worksites, physician’s offices, or hospital to provide management of services
Participate with other care team members in regular or special meetings such as Clinical rounds
Perform other duties as assigned
KNOWLEDGE, SKILLS & ABILITIES

Interpersonal savvy, with the demonstrated ability to interact with and influence people to establish trust and build strong relationships
A high sense of urgency and can-do attitude required for a role at a start-up company
Strong organization skills and ability to manage and maintain a personal schedule
Ability to establish priorities and meet deadlines
Ability to work independently within a virtual operating environment and as part of a team
Excellent oral and written communication skills
Ability to conduct written and oral instructions
Ability to exercise judgment in the application of professional services

Requirements
REQUIRED QUALIFICATIONS

Unrestricted registered nursing license in the state(s) of care management activities a minimum requirement
Travel to patient’s home, provider’s office, hospitals, etc., required with dependable car
Must be willing to spend 70% of time traveling in the field
Demonstrated expertise in care management and coordination across all healthcare providers, patient, and caregivers
Experience with completing real-time documentation in EHR and/or Care Management systems
Ability to effectively communicate across a multitude of key care partners
Ability to motivate patients and caregivers to follow care plans and optimize self-care potential
Excellent documentation skills with the ability to manage multiple patient cases
Sound critical thinking to assess, analyze and monitor outcomes to recommend the optimal plan of care
Computer literacy and ability to effectively communicate within the business structure
PREFERRED QUALIFICATIONS

3+ years of care management experience in an outpatient setting preferred
3+ years in a hospital, health plan or related healthcare business entity also considered
Experience serving the Medicare, Medicaid, and Duals population
Proven experience working independently seeing patients in the community
Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position. All individuals selected for a position will undergo a background check appropriate for the position's responsibilities.

**We require all our employees to be vaccinated and to show proof of vaccination upon hire**