Role Summary
The individual in this role is a member of the Interdisciplinary Care Team and will work in collaboration with the team to deliver and manage all aspects of participant care. Responsibilities include conducting required assessments, developing and following individualized participant care plans, addressing patient needs, and advocating for participant needs to be met. In partnership with the Primary Care Provider, this role involves delivering care in various settings such as the center, participant's homes, skilled nursing facilities, or any other type of short-term or long-term care setting.
Duties and Responsibilities
- Take ownership of the outcomes and quality of care for assigned participants, working directly with the PCP and utilizing other clinic resources.
- Conduct in-clinic, at-home, and virtual assessments, educate participants and their support network, and perform follow-up visits as needed.
- Develop and implement a discipline-specific plan of care in collaboration with the interdisciplinary team, participants, and families to ensure delivery of high-quality, value-based, holistic, and compassionate care.
- Identify participants' overt problems and needs, determine priorities, and collaborate effectively with other team members.
- Coordinate care for participants with complex needs, ensuring seamless transitions of care and preventing unfavorable outcomes.
- Attend to clinical inbox tasks, ensuring timely completion of orders, review of test results, and appropriate documentation and communication.
- Perform and document ordered procedures and care in clinic or at home visits when necessary.
- Communicate participant changes to the interdisciplinary team, including post-procedure or post-discharge needs.
- Coordinate with the Complex Care Team on participant discharges and transitions of care.
- Review medical test results and evaluations, working with providers on timely responses and ensuring appropriate follow-up.
- Provide support on specific and relevant tasks in the absence of certain clinic roles.
- Act as a coordinator of care, evaluating and following up on patient care measures.
Required Skills & Experience
- Minimum of two years of nursing experience in a clinical setting with a frail or elderly population.
- Nursing knowledge and skills necessary to treat frail, elderly participants and manage complex clinical situations.
- Highly motivated, self-directed, and able to execute tasks in a quickly changing environment.
- Excellent clinical, organizational, and communication skills in settings with seniors, their families, and interdisciplinary team members.
- Ability to work independently with minimal supervision and prioritize in a fast-paced environment.
- Experience and competency working with people from diverse backgrounds and cultures.
- Commitment to unlocking the full potential of vulnerable seniors.
Preferred Skills & Experience
- Bilingual English/Spanish preferred.
Schedule Notes
The schedule is Monday through Friday, 8 a.m. to 4:30 p.m. This position includes two mobile days a week for seeing patients in their homes and three onsite days. Responsibilities include patient care, case management, patient assessments, education, and coordination of patient communication and needs. Reliable transportation is required for this role.