[Hiring] Value-based Care Registered Nurse @Herself Health

Role Description

As we grow our early team, we are seeking strategic thought leaders who have a passion for building and innovating. We foster a culture of collaboration, excellence and the willingness to roll up our sleeves and learn as we grow. We have a customer first mindset, and we are looking for team members who share that. Our ideal candidates have strategic prowess and the ability to use data to build best practices and implement great ideas in collaboration with our team and our community.

Within a value-based and patient-centered model of care reporting to the Company's Lead Registered Nurse, the Registered Nurse (RN) at Herself Health provides exceptional care to women ages 65 and up. Through Transitional Care Management and Triage, the RN educates and empowers women to manage their health conditions and achieve their individual goals of care. The RN role facilitates collaboration and continuity of care among team members, including providers, medical assistants, and health coaches.

Essential Functions

• Transitional Care Management (TCM):
  • Focused on outreach during the 30 days after discharge with the goal of reducing ER visits, hospitalizations, readmissions, and post-acute stays.
  • Reviews daily ADT feeds and initiates contact with patients within 2 days of discharge.
  • Schedule follow-up for TCM visit with the PCP within 7 days of discharge.
  • Complete weekly outreach for 30-day post-discharge.
  • Review discharge plan and ensures services (e.g. Physical Therapy, Home Health) are in place; provides community resources for SDOH (Social Determinants of Health) needs.
  • Provides patient/family education regarding health conditions and disease self-management.
  • Completes medication reconciliation and monitors adherence.
  • Documents all telephone/video interactions in EHR patient chart.
  • Identifies patterns and episodes of care that are predictive of future needs and services.
  • Coordinates care with other providers involved in the patient’s care as needed.
• Triage:
  • Respond to patient telephone calls, refill requests, and electronic health messages.
  • Demonstrates critical thinking skills and expert nursing judgement to provide appropriate recommendations for care utilizing an approved evidence-based telephone nursing triage protocol.
  • Works with the RN scope of practice and standing orders to provide prescription refills, medication titration, and home treatments.
  • Educates patient regarding test results and medical conditions, and explains medical terms and procedures.
  • Maintains a professional demeanor and focus on patient-centered care.

Qualifications

• An active, unrestricted Minnesota RN license required, or ability to obtain by start date. Multi-state compact license preferred.
• Willingness to obtain additional cross-state licensure as needed.
• Minimum of 2 years’ experience as an RN in clinical setting.
• Prior experience working as a triage RN or RN case manager required.
• Exceptional communication skills and patient-centered focus.
• Ability to monitor and evaluate opportunities for cost-effective care with high-quality outcomes.
• Demonstrate effective, independent nursing judgement and skills.
• Demonstrate skill and experience in effectively collaborating with care team members.
• Demonstrate skill in effective use of electronic health records.
• Demonstrate flexibility, organization, and appropriate decision-making in ambiguous situations.

Nice-to-have Qualifications and Skills

• Prior experience working in telephonic case management preferred.
• Knowledge of Medicare and NCQA regulatory transitions of care preferred.
• Experience in value-based care preferred.

Company Description

At Herself Health, we're on a mission to help women get more life out of life, together. We are building a new model of primary care for women 65+ to solve long-standing problems: rushed appointments, long wait times, and care that's generalized rather than specialized towards women’s needs later in life such as post-menopausal care, bone density, weight management, and mental, social and emotional well-being.

Our patient-centric Primary Care clinics are dispersed across Minneapolis/St. Paul, MN. We are thrilled to serve the Twin Cities metro and Eagan. Our team of 100+ colleagues is on a mission to innovate the primary care landscape for women 65+. We’re seeking like-minded individuals who share this passion to join us!