Overview:

#The Power to impact lives

GREAT NEWS! NOW HIRING Population Health Nurse!!

Working outside the four walls of a facility or hospital is the dream for many.. .join our team to live the dream.

You'll make a difference every single day by providing direct patient care to individuals in their own home environment after their acute stay or surgery. Practice nursing independently, outside the four walls of a hospital or facility, and work with a team that values your critical thinking skills to care for the most vulnerable patients in our communities. Thrive every day through freedom, flexibility and a fast-paced, ever-changing, never-the-same-day-twice environment!

Responsibilities

Dignity Health at Home is growing and wewelcome YOU to be a part of a great team and a mission

We believe in putting our clinicians first which in turn, puts our patients first.

This position will be seeing patients with Congestive Heart Failure that are part of our High Utilization Group (HUGS) program. We have partnered with our hospitals and Transition Care Clinics to create a unique program intertwining advanced practitioners and our home health team tokeep our patients that are at the highest risk of re-hospitalization safe in their home. Our partnership with ExactCare has proven to reduce re-hospitalizations due to medication errors and we utilize only the best wound products and advanced education for our clinicians to ensure positive wound healing and outcomes for our patients.

This program provides lcose monitoring and medical support following a patient's hospital discharge, which will facilitate a seamless transition home. Our goals are to optimize the patients's current treatment plan and provide an individualized care plan that meets the patient's needs

Provides care and education to patients and their caregivers

Participates in the coordination of services with other disciplines and community resources as needed

Evaluates and revises care plans/assessments based on changes in patients and/or their environments.

Partificaptes in regular case conferences and in-service orspecial case orientations as needed and participates in on-call rotation.

We leverage tele-monitoring as a core component of our case management approach.

• Partnered with Health Recovery Solutions (HRS)
• Use of electronic information and telecommunications technologies to support clinical health care by providing accessible, cost-effective, high-quality health care services.
• Decreases drive time, increases patient engagement and promotes independence in self-care management
• Reduces hospital re-admissions and avoids unnecessary emergency department visits
• Optimizes operational and clinical workflow

Qualifications

• Must be a graduate of an accredited school of nursing and licensed (RN) in the state in which currently practices
• Minimum one year nursing experience in a division working with home health or Hospice in the last 36 months.
• Able to problem solve effectively.
• Capable of prioritizing and handling multiple tasks of critical importance simultaneously.
• Able to function well in atmosphere of stress and interruption. Competent with computers; organized; detail-oriented; effective oral and written communication skills.
• Prior review/QI experience; OASIS certification
• Medicare home health experience.