About the role:
Transitions of Care (TOC) RNs are a key part of our Accompany Health care model which also includes Physicians, Advanced Practice Clinicians, Community Health Workers, Patient Experience Navigators, RNs, Social Workers, Behavioral Health Clinicians, Psychiatrists, and Pharmacists. Together this team is responsible for providing and coordinating holistic, patient-centered care for an intimate panel of patients with complex medical, behavioral health, and social needs. As a TOC RN, you will help ensure our patients have the care they need after a vulnerable time period post-discharge from the Emergency Department or hospital. As a TOC RN, you will care for patients virtually via video, telephone, or text.
As part of the central nursing team, you will help provide transitional care for patients in various cities. You will contact patients who have recently been discharged and conduct a clinical assessment and medication reconciliation, and will help patients who require additional care with scheduling follow up appointments as needed. You will also occasionally contact local hospitals when needed to collaborate with the inpatient team to coordinate safe discharge planning.As part of the TOC role, you may also help provide proactive outreach virtually for some of our complex patients who have frequent admissions.
You will support the local care team responding with compassion and empathy, uncovering barriers and connecting patients with appropriate care and resources that can keep them safely at home and out of the hospital when possible.
Responsibilities will include:
- Providing post-discharge follow up care for patients virtually via video, telephone, or text
- Providing patients with education on their care plans and medications.
- Effectively interpreting and utilizing electronic data tools and analysis to organize daily activities and provide high quality of care
- Collaborating closely with local Accompany Health teams to ensure continuity of care
- Establishing and fostering trusting relationships with your patients and ensuring that care is appropriately aligned with their goals and values
- Collaborating with external hospitals when necessary to collaborate on discharge planning and advocate for patient care aligned with their goals
- Providing feedback on program design and workflows to ensure we are providing the best patient care possible.
- Timely and appropriate documentation.
- Roles and responsibilities may evolve as our care model develops.
- Occasional in person team building time
What makes you a fit for the team:
- Passionate about caring for complex, historically underserved patients with co-occurring chronic and behavioral health conditions in an integrated, multi-disciplinary model anchored in home-based and tech-enabled virtual care.
- Committed to providing the highest quality, outstanding clinical care to all patients, regardless of their needs.
- Strong proficiency in using technology and delivering a high caliber of care virtually.
- Excellent communicator, collaborator and team player who enjoys working in an integrated, multi-disciplinary model.
- Committed to providing the highest quality, outstanding clinical care and willing to go the extra mile for all patients.
- Possess high attention to detail as well as adaptability, and is excited to be a part of and contribute to the development of a rapidly evolving, innovative care model.
- Enjoys continuously learning and adapting workflows to improve patient care.
Desired skills and experience:
- Required
- Active, unrestricted Registered Nurse license in home state and willingness and certification in good standing and the ability to get licensed in requested states such as Michigan, Colorado or Massachusetts within 90 days of hire date.
- 3+ years of experience providing clinical services to Adult and/or Geriatric individuals with co-occurring chronic medical and behavioral health conditions, particularly in virtual settings.
- Demonstrated ability to help a patient adapt new habits, change behaviors, and motivate towards achieving health goals.
- Comfort with electronic medical record documentation and excited about how technology can support your work and drive ongoing improvement towards new and better care
- Experience and comfort working within an interdisciplinary care team, and specifically communicating with clinical and non-clinical team members.
- Preferred
- Experience in adult internal medicine, family medicine, geriatrics, palliative care, and virtual care.
- Experience in transitions of care management for patients being discharged from hospitals, skilled nursing facilities, and behavioral health facilities, including performing detailed medication reconciliation, patient education, and connection/navigation to appropriate services.
- Experience in behavioral health settings and/or caring for patients with serious mental illness and/or substance use disorder.
- Experience in trauma-informed care and practices.
- Experience as an active participant in continuous quality improvement projects.
- Experience in value-based care organizations
$85,000 - $95,000 a yearThe US base salary range for this full-time position is $85,000-$95,000 + bonus + equity + benefits. Our salary ranges are determined by role, level, and location. The range displayed on each job posting reflects the minimum and maximum target for new hire salaries for the position. Within the range, individual pay is determined by work location and additional factors, including job-related skills, experience, and relevant education or training. Our talent team can share more about the specific salary range for your preferred location during the hiring process.Apply for this job
