ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Provides in home and telephonic visits to patients at high-risk for hospital admission and readmission (as identified by CM Plan). Main goal to prevent and admission or readmission to the ER/hospital .
• Provides home visits to perform initial assessment of patient and the development of care plan for the Licensed Practical Nurse (LPN) to use as they perform the follow up patient visits, once patient has completed their episode of care management the register nurse (RN) will review patient chart for discharge and conduct final discharge with patient.
• Conducts supervisory visits with License Practical Nurse (LPN) and patient to provide any additional education patient may need and to oversee appropriate patient discharge from case management.
• Performs clinical and Social determination of Heath screening (SdoH) assessments to include disease-oriented assessment and monitoring, medication monitoring, health education and self-care instructions in the outpatient in home setting.

Coordinate the Plan of Care:

• Provides oversight for the License Practical Nurse (LPN) with clear plan of care and education which is mandatory during all LPN visits.
• Conducts/coordinates initial case management assessment of patients to determine outpatient needs.
• Ensures individual plan of care reflects patient needs and services available in the community or review of their benefits.
• Completes individual plan of cares with patients, family/care giver and care team members.
• Communicates instructions and methodologies as appropriate to ensure that the plan is implemented correctly.
• Assesses the environment of care, e.g., safety and security.
• Assesses the caregiver capacity and willingness to provide care.
• Assesses patient and caregiver educational needs.
• Coordinates, reports, documents and follows-up on multidisciplinary team meetings.
• Helps patients navigate health care systems, connecting them with community resources; orchestrates multiple facets of health care delivery and assists with administrative and logistical tasks.
• Coordinates the delivery of services to effectively address patient needs.
• Facilitates and coaches’ patients in using natural supports and mainstream community resources to address supportive needs.
• Maintains ongoing communication with families, community providers and others as needed to promote the health and well-being of patients.
• Establishes a supportive and motivational relationship with patients that support patient self-management
• Monitors the quality, frequency, and appropriateness of HHA visits and other outpatient services.
• Assists patient and family with access to community/financial resources and refer cases to social worker as appropriate.
• Home visit under the direction of the patient’s primary care physician to meet urgent patient needed.
• Performs other duties as assigned and modified at manager’s discretion.

Job Type: Full-time

Pay: From $80,000.00 per year

Standard shift:

• Day shift

Supplemental pay types:

• Bonus opportunities
• Quarterly bonus

Weekly schedule:

• Monday to Friday

Work Location: Hybrid remote in Louisville, KY 40211