Community Health Nurse (RN)

Baltimore, MD
Jun 09, 2019
Jun 17, 2019
Community Health
Contract Type
Community Health RN

The Home-Based Care Manager position, which utilizes a broad range of skills, clinical expertise and proficiency in complex case management, will manage the transition and care coordination of at-risk members during the 30 - 45 days following discharge from an inpatient facility. The Home-Based Care Manager will make visits to members at their place of residence, perform assessments, evaluate members progress, communicate to the AbsoluteCARE Team, provide care plan interventions, coordinate care and ensure quality service. The Home-Based Care Manager will have strong communication and leadership skills as well as the ability to work autonomously in the field while being accountable to the AbsoluteCARE team at the practice site. The Home-Based Care Manager will have enthusiasm about coaching, educating and supporting members post discharge and will be highly motivated to help our company fulfill its larger mission of providing patient centered ambulatory ICU service and complex case management for our vulnerable and at-risk members. The Home-Based Care Manager will be people-centered, supportive and flexible to optimize his/her members potential, by inspiring members to be responsible for their health and developing the necessary self-management skills to improve quality of life, health outcomes and increase appropriate health services utilization.

Duties and Responsibilities
  • Provide in home face-to-face case management services to vulnerable and members at risk for unnecessary emergency room utilization and avoidable hospitalizations;
  • Perform comprehensive assessments to evaluate member's medical, social and behavioral needs while identifying member/family strengths, health behaviors, social determinants of health, barriers, and resources;
  • Develop a strong collaborative relationship with the AbsoluteCARE Transitional Care Manager to actively manage the member during the 30 - 45 days post discharge;
  • Extend care plan interventions in the home and ensure timely follow-up at 48 hours, and 7 - 14 days post discharge;
  • Creatively approach problems, uses out of the box thinking with solutions-oriented behavior and utilize all available resources to overcome barriers, address social determinants of health, improve health literacy and patient engagement;
  • Communicate, participate and act as an extension of the AbsoluteCARE multi-disciplinary team comprised of primary care providers, care managers, transitional care managers, social workers, registered dietitians, pharmacists, behavioral health clinicians, medical assistants and outreach workers;
  • Collaborate with inpatient facility teams comprised of hospitalists, case managers, discharge planners, social workers, charge and staff nurses and with AbsoluteCARE's multi-disciplinary team to facilitate post discharge instructions and treatment in the home;
  • Coordinate with inpatient facility care teams, AbsoluteCARE multi-disciplinary team, patient, family, and caregivers to help resolve barriers to care and transition member back to AbsoluteCARE's Ambulatory Care ICU - Patient Centered Medical Home Center;
  • Intervene prior to or at time of condition exacerbation or decline in medical and/or behavioral health to help members appropriately utilize healthcare services - the right place, at the right time for the right condition and intensity of service needed to avoid unnecessary emergency room visits and avoidable hospitalizations;
  • Establish & maintain strong collaborative working relationships with inpatient facilities and community care organizations like home health agencies, social services and hold meetings with these entities regarding AbsoluteCARE population needs;
  • Advocate on member/family's behalf and support engagement through warm handoffs and timely, relevant and proactive communication;
  • Meet deadlines and manages competing priorities;
  • Other duties as required.

  • Registered Nurse with 3 + years related case management experience, with 3 + years of diverse clinical background in >2 care settings (hospital, SNF, home health, rehab etc.);
  • Home Health, Psychiatric and Substance Use Disorder experience helpful;
  • Bachelors with case management certification preferred;
  • Excellent communication and leadership skills;
  • Self-starter with great organizational skills and attention to detail;
  • Experience with analyzing and leveraging the reporting capabilities of Electronic Medical Records;
  • Extensive knowledge of city's population, geography, and resources;
  • Experience working with high risk and medically complex patients with multiple comorbidities;
  • Effectively adapt to a complex, fast-paced, and results-oriented environment;
  • Working knowledge of Microsoft Office Suite (Word, Outlook, PowerPoint, and Excel);
  • Handle confidential health care information following all HIPAA guidelines.

Company Description

AbsoluteCARE provides comprehensive primary health care to adolescents (16 years and older) and adult patients. Our comprehensive approach is specifically geared towards care for health, wellness and prevention. Our practice specializes in the management of chronic conditions such as diabetes, hypertension, COPD, heart disease, congestive heart failure and asthma.

We aim for the highest quality and most cost effective medical and wellness care in a private setting that offers comprehensive medical, laboratory, pharmacy, radiology, nutrition, educational and support services. AbsoluteCARE provides Compassionate, Confidential, Comprehensive and Culturally-Effective Care for Patients and their Families.

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