RN

EverCare Registered NurseThe EverCare Registered Nurse is a core member of the geriatric primary care interdisciplinary team, working in close partnership with the Nurse Practitioner, Medical Assistant, and collaborating physicians to deliver proactive, coordinated, patient-centered care to medically complex older adults. The EverCare RN owns the chronic care management function of the practice, serving as the primary point of contact for an assigned panel of patients between provider visits. This role is central to the practice’s success in the Accountable Care Organization (ACO) and other value-based arrangements: the RN delivers and bills Medicare Chronic Care Management (CCM), Principal Care Management (PCM), and related care management services; supports Transitional Care Management (TCM) and Annual Wellness Visits (AWVs); closes quality and care gaps; and works to prevent avoidable emergency department visits, hospitalizations, and readmissions. Strong clinical assessment, telephonic triage, and therapeutic communication skills are essential, as is the ability to guide goals-of-care and advance care planning conversations with empathy and professionalism.