Registered Nurse

Why Join Grace at Home?
Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient s race, culture, and environment is critical to delivering improved health outcomes. By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality not a burden every single day. Join us in creating a better way to care.
Overview
The RN reports to the Clinical Manager or designee, with accountability for providing strategy, judgment, organization, and evidenced-based analysis to influence decisions, and directly to meet Grace at Home s requirements. They should embody Grace at Home s core values, including, Trusted , Empathetic, Committed, Humble, Creative and Community-Minded . At Grace at Home, we don t have patients or customers we have Family Members.
Grace at Home model is designed for member engagement of the high-risk population with an emphasis on event-driven care management leveraging care pathways and evidenced based guidelines tailored to black and brown populations. Care Management includes assessing healthcare needs, identifying problems and opportunities for improvement, implementing Nursing Care Plans, managing the patient care transition process, assisting patients throughout care episodes, coordinating, and facilitating care for patients with complex, chronic medical and mental health conditions, providing disease education, and promoting evidence-based healthcare services. The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for patients/families struggling with chronic disease management. It is critical that care management be done in conjunction and always with the Caregiver, including their and the member s signoff. Conducting Caregiver assessments are also part of the Care Management process.
The Grace at Home program is designed to provide additional support to our patients by providing an integrated level of equitable value-based medical care and social support in the comfort of where our members call home. This program is offered to eligible health plan patients with the primary goal of mitigating adverse health complications, unmanaged disease progression and ultimately avoid unnecessary hospitalization that can occur when timely clinical interventions are not provided or are not accessible.
In this role, you'll collaborate closely with a multi-disciplinary clinical team to deliver high-quality, personalized care in both a home-based and telehealth setting. The ideal candidate is committed to providing longitudinal care to build meaningful patient relationships, improving patient outcomes, and eager to make a meaningful impact in underserved communities.
Primary Responsibilities & Duties:

• The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for Grace at Home s members/families struggling with chronic disease management.
• Works with member and care team to conduct appropriate assessments that result in a nursing care plan prioritized by the patient and caregivers.
• Conducts in-home or tele-health assessments, as directed by the model and leadership
• Track nursing care plan outcomes, interventions, and continue to reassess the patient's needs as appropriate.
• Utilizes care pathway templates by condition with risk levels and member actions by event type.
• Deploys Remote Patient Monitoring and Patient Self Reporting for High-Risk Chronic Conditions.
• Conducts transition of care visits both virtually and in-home to ensure smooth transition from an acute care setting to home.
• Provide care coordination for Grace at Home s Family Members including patient navigation, chronic disease management/education and interdisciplinary collaboration while complying with department policies and procedures and other contractual requirements.
• Engage members in taking a proactive role for managing their health, medications, treatment and mental health needs, and follow-up appointments and refer patients to the appropriate community-based organizations or other programs.
• Follow evidence-based guidelines to facilitate closure of gaps in care and encourage and use of in-network services if appropriate and determine when in-home services are needed and ordered.
• Use the electronic medical record or clinical management platform to conduct care coordination activities and comply with associated policies and procedures including those for workflow and consistent documentation.
• Participate in team-based rounds to support and contribute to ongoing program design and development as lessons are learned from the field and process improvement work performed within the department.
• Demonstrates an ability to identify and shift priorities within work assignment to effectively manage patient care load.
• Perform other job-related duties as assigned.
• Leadership : The RN will lead in defining and executing strategies and solutions to create business value in the clinical practice, including working with their team to design, develop, and execute those strategies and solutions to deliver desired outcomes.
• Strategy : The RN will establish the business strategy and roadmap: (1) improve outcomes for Grace at Home Family Members; (2) enhance the efficacy of other Grace at Home business divisions; and (3) develop and deliver external market opportunities for Grace at Home products and services. In establishing the business strategy, the RN Advocate will define and innovate sustainable revenue models to drive profitability of the Company.
• Collaboration : The RN will ensure that our clinical capabilities form a cohesive offering, including by working closely with other business divisions to learn their needs, internalize their knowledge, and define solutions to achieve the business objectives of Care at Home.
• Knowledge : The RN will provide subject matter expertise in the clinical solutions, including determining and recommended approaches for highest quality medical care, including assessment and event-based care management
• Culture : The RN is accountable for creating a productive, collaborative, safe and inclusive work environment for the clinical team and as part of the larger Company.

Qualifications

• Education: BSN Required. MSN or other healthcare related graduate level degree, a plus.
• Experience: At least 3 to 5 years of relevant clinical experience. Ideal candidates will have 3+ years of relevant care management experience in a health plan, hospital, home health and or hospice.
• Unrestricted RN licensure in the state of the hiring Grace at Home location; preferably an enhanced-compact-multi-state license (eNLC) to potentially support other locations, as necessary
• Knowledge and prior use of Microsoft Office products or other similar office software
• Unrestricted driver s license in the state of hire
• Experience with EMRs
• BLS certification

Competencies

• Analytics/Critical Thinking : Ability to examine/analyze and evaluate information to form a reasoned judgement on the information presented.
• Assessment Skills : Utilize the nursing process to evaluate a member s bio-psychosocial conditions. Use evidence-base practices as a model for care delivery.
• Problem Solving : Ability to identify a problem, consider options and implement a solution to achieve a desired outcome
• Communication: Excellent verbal, written communication, and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner.
• Relationships: Ability to build and effectively manage relationships with patients, the community business leaders, and external constituents.
• Culture: Good judgement, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial Company.

The working environment and physical requirements of the job include:
This position requires in-home, assisted living, and independent-living community-based work. The job requires frequent travel for patient visits in all types of weather conditions. Work may be performed in settings with conditioned air, artificial light, and an open workspace.
In this position you will need an ability to travel frequently by car and/or public transportation, the ability to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting or standing for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 50 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.
Our Benefits
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