RN, High Risk Transitions Nurse

RN, High Risk Transitions Nurse Northwest Physicians Network is now offering qualified candidates an opportunity to join our team as a RN, High Risk Transitions Nurse. Our company values innovative problem solvers promote personal and professional growth and provides a supportive working environment that affords all of its employees a healthy work/life balance. Under minimal supervision, supports the delivery of cost-effective coordination of care, transition of care and utilization management. Primary responsibility is to provide member care management services for high-risk members in alignment with clinical utilization review for delegated health plans and transition of care. Work collaboratively with multiple disciplines and resources to facilitate transitions of care for the member. Incorporates nursing process, standard work, critical decision-making skills and care management services while developing and implementing plan of care designed to meet the members 30-day post hospitalization needs while ensuring continuity of care. Assess, facilitate, plan, and advocate for health needs on an individual basis resulting in quality, cost-effective outcomes. Northwest Physicians Network creates the opportunity for independent private practitioners to thrive in Washington State. By providing clinical integration support and data driven quality improvement, we have created a high value delivery network, making it possible for our providers to remain focused squarely on their patients.Status: Regular, Full-time, FLSA Non-exemptCompetitive BenefitsPrimary responsibilities will include:The duties listed below are intended only as illustrations and guidelines for the various type of work that may be performed. Understands role in reducing hospital admissions and readmissions with timely clinical decisions of medical necessity and coordination of care with clinical teammates and outsider providers.

Provide telephonic post discharge support within 1-2 business days of discharge.

Ensures post hospitalization follow up with PCP or other provider is scheduled within 7 days, medication reconciliation is completed, and contingency plan is created. Ensure other post hospitalization follow up appointments are schedule as warranted

Plan and coordinate activities related to transition planning.

Develop and implement plan of care designed to meet the member’s 30-day post-hospitalization needs while ensuring continuity of care.

Enrolls high risk members into High Risk Transitional Care program to monitor for 30 days post discharge. Telephonic support per HRTC program guidelines.

Collaborate with medical staff, Primary Care Physician, member’s family, community agencies or facilities involving in member’s care, and the health care team.

Assess, facilitate, plan, and advocate for health needs on an individual basis resulting in quality, cost-effective outcomes.

Facilitate and plan family care conferences as needed.

Provides hand offs for members who transition to the next level of care

Refers members who could benefit from case management, disease management or other continuum programs which contributes to improved quality of care and lowers cost of care.

Delegates appropriate tasks to care coordination teammates.

Ensures confirmed start date for Home Health services if ordered

Knowledge, Skills, and AbilitiesWorking knowledge of health care delivery systems

Demonstrate knowledge of PC applications including MS Office Suite

Ability to use written and oral communication skills

Ability to read and interpret data

Skill in writing clear, grammatically correct, easy–to-use instructional documentation

Ability to identify learning needs, set goals and seek educational opportunities

Ability to analyze problems and formulate appropriate plans, solutions and courses of action

Knowledge of age specific communication needs with the ability to listen actively and respond to internal and external customers in a timely, competent manner both verbally and nonverbally

Ability to work with frequent interruptions

Ability to establish and maintain cooperative working relationships with individuals at all levels of the organization and affiliates

Ability to maintain confidentiality of member and all related entity business matters of the organization and its partners

Ability to manage detail and work with accuracy

Ability to recognize and act appropriately in situations where member care needs exceed medical certification

Skill in working with a team; ability to collaborate on projects with colleagues

Skill in working effectively under deadlines and changing priorities

Minimum Requirements:Education: RN, BSN or above preferred from accredited nursing program

Experience: 2 years- broad-based clinical experience

Certification/License: Current unrestricted nursing license for the State of Washington, case management certificate preferred, mandatory after two years of employment.

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM) Diversity creates a healthier atmosphere: Optum and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Optum and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.