LOCATION: Remote - must live in North Carolina or within 40 miles from the NC border.

GENERAL STATEMENT OF JOB

Performs nursing assessment and support for adult members that are medically fragile or have significant chronic health conditions, have a mental health, substance use or co-occurring disorder who are transitioning out of a Skilled Nursing Facility (SNF) into the community. Individuals served may also have a co-occurring intellectual or developmental disability. This position will work collaboratively with other Vaya staff, behavioral health providers, Primary Care Physicians, specialty care providers, Skilled Nursing Facility providers and other community partners and stakeholders to support members in their home communities. Work is performed under the supervision of the Transition and Housing RN/OT Manager.

The role can involve a range of scenarios which require a wide array of potential responses including micro and macro level interventions. These may include, but are not limited to assessment, care monitoring, and care planning, discharge planning, patient and family education, medication reconciliation, researching, linking, reviewing documentation, phone communication, and virtual attendance at treatment team meetings. The nurse on this team will be in a consultant role with virtual visit capabilities. The nurse may, assess health literacy, provide patient and family education, partner with Skilled Nursing Facility administration, ACTT Nurses, home health agencies, CAP/DA, PACE, EMS, or other medical providers.

ESSENTIAL JOB FUNCTIONS

Assessment, Coordination, Care Plan Development and Safety Oversight:

• Proactively ensures individuals identified as transitioning out of Skilled Nursing Facilities ACHs and/or Special Needs enrollee receive RN Assessment and are linked to a Behavioral Health Clinical Home and a Medical Home
• Coordinate community service planning and attend care team meetings (virtual).
• Ensure service needs are addressed and coordinate the collection, entry, maintenance, analysis and reporting of data associated with psychiatric and medical treatment.
• Assist in development of participant care plan and discharge plan
• Appropriately escalates high risk scenarios to appropriate leadership. High risk can involve Health & Safety of an individuals served, staff or organizational risk
• Provides Medication Reconciliation
• Uses data, assessment, chart review and supervision to measure results of interventions and treatment, including reduction in high-risk events
• Ensures that services for the individual are coordinated across the Vaya Health system and with other healthcare and social determinant systems
• Understand the role of and collaborate with Transition and Housing teams, Acute Response team, Hospital Emergency Department, Skilled Facility, or Inpatient Discharge planning teams, participate in developing transition plans, educating staff and members regarding network services and supports with consideration of medical necessity, funding eligibility and appropriateness of recommendations relative to person centered, recovery principles and known best/appropriate practice.

Collaboration:

• Develop relationships with community stakeholders to streamline service provision to members and efficient use of professional resources.
• Partner with primary care providers, specialty care providers, behavioral health providers, home health care and personal care providers, skilled nursing facility care providers, as well as other stakeholders.
• Proactively works with team to identify gaps in services and intervenes to ensure that the individuals and specialty populations receive appropriate care
• Provides support to team addressing barriers to care for members through convening key providers and others to address needs of the individual or populations at the individual or system level

Documentation:

Staff Education:

KNOWLEDGE, SKILL & ABILITIES

• Timely and complete documentation regarding member specific interactions is required.
• Effective care coordination requires a detailed knowledge of the state plan, service availability, service definitions, network providers, community resources, mainstream and alternative funding sources.
• Requires clinical knowledge, awareness of community resources, strong communication skills, effective problem-solving abilities, and an ability to apply these skill sets across diverse and complex situations.
• Clinical knowledge of Minimum Data Set (MDS) System and how to implement strategies to serve individualized needs with activities of daily living and instrumental activities of daily living.
• Understanding of Medicare and dual enrollment when obtaining resources and requirements for Durable Medical Equipment (DME).

QUALIFICATIONS & EDUCATION REQUIREMENTS

Associate Degree in Nursing with licensure as a Registered Nurse in North Carolina and two (2) years of experience as an RN is required. Bachelor's degree in Nursing preferred. Experience working in a skilled nursing facility preferred.

Licensure/Certification Required:

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.