Complex Care Specialist

Company: WelBeHealth
Location: Myrtle Point
Posted on: June 23, 2022

Job Description:

At WelbeHealth, we make the impossible, possible for underserved seniors. We do this through utilizing and developing cutting-edge healthcare and well-being service products especially for seniors and their families. Now is your chance to join our talented team that delivers unparalleled creative healthcare, insurance, social support and more to seniors. We create senior well-being through our courage to love, pioneering spirit and shared intention. These values permeate everything we do. At WelbeHealth, you'll help inspire that magic by enabling our teams to push the limits of healthcare and well-being experiences and create the never-before-seen!The Complex Care Nurse is primarily responsible for facilitating participant care transitions and managing ongoing care coordination between nursing homes, hospitals, B& C facilities and hospiceand the WelbeHealth teams. The Complex Care Nurse supports the local markets to manage care coordination for the most complex situations, and to support the efficient operation of the WelbeHealth primary care clinic. The Complex Care Nurse also collaborates effectively with colleagues and stakeholders to promote the WelbeHealth values, team culture and missionWhat you'll do:Daily hospital concurrent reviews and coordination of discharge.Initiate and coordinate smooth care transitions for WelbeHealth participants determined by the IDT to need nursing home, hospitals, board and care (B& C) facilities and hospice services.Implements a comprehensive transition plan for each participant admitted to the hospital, ER, or skilled nursing facility.Monitors and tracks participants' course in the hospital and skilled nursing facility and assist in coordinating the care between the hospital or SNF teams and PCPs in coordinating the care.Facilitates coordination of care between the providers and those of nursing homes, hospitals, B& C facilities and hospicefor participants receiving those services which includes coordinating visits and care conferences.Prepares for and leads Transitions of Care meetings and discussions.Collaborates in the care process to assess, plan, facilitate, coordinate, monitor, and evaluate options and services to meet participant's health needs.Supports participant or their representative in regard to care, care transitions, and changes in health status.Tracks all participants admitted to the hospital for at least t30 days post-discharge and ensures appropriate follow up. Performs skilled Nursing Facility concurrent review, assess skilled need, authorize, and drive appropriate discharges.Assists with placement for most challenging participants from outpatient to skilled or inpatient facility, locate accepting.Assists in COSA with scheduling and coordinating outpatient procedures when needed.Assists with weekly outreach calls to the highest risk participants (Red).Assists with LOA process to aid with rapid transfers and placement.Performs utilization review for pended claims and drivers of highest cost to ensure that we deliver high quality of care in the most cost-effective way using most appropriate levels of services for the participants.Collaborates with the network contracting team to identify and select additional contracted nursing home, B& C facilities and hospicecompanies to meet needs of WelbeHealth participants.Performs and document data collection (e.G., vitals) as assigned.Provides back up to other nursing staff as neededAccurately responds to physician orders and coordinates care accordingly.Remains alert to pertinent input from other team members, participants, and caregivers and update other clinical staff promptly of any changes in participants' condition or medical status.Instructs the participant, family and caregivers regarding the disease process, self-caretechniques, and prevention strategies, as assigned.Always works within LVN scope of practice and under supervision of RN, NP or MD.Be legally authorized to practice in position location, required.Complete all required documentation in a timely and accurate manner.Protect privacy and maintain confidentiality of all company procedures and information about team members, participants, and families.Follow policies and procedures and participate in any required Quality Improvement activities, staff training and meetings.Communicate regularly with Supervisor and team regarding workload and priorities.Exercises flexibility in performing assignments as business needs evolve.Other duties as assigned.Your qualifications:Graduate of an Accredited School of NursingUnencumbered LVN/RN License in CaliforniaMinimum of one year of nursing experience in a clinical setting with a frail or elderly populationNursing knowledge and skills necessary to treat frail, elderly participants and manage complex clinical situationsHighly motivated, self-directed, able to execute tasks in a quickly changing environment and make sound decisions in emergency situationsExcellent clinical, organizational and communication skills in settings with seniors, their families and interdisciplinary team membersExcellent organizational and communication skillsBilingual English/Spanish preferredCommitment to unlocking the full potential of our most vulnerable seniorsCOVID-19 Vaccination PolicyAt WelbeHealth, our mission is to unlock the full potential of our vulnerable seniors. In this spirit, please note that we have a vaccination policy for all of our employees and proof of vaccination prior to employment is required.Our Commitment to Diversity, Equity and InclusionAt WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.

Keywords: WelBeHealth, Medford , Complex Care Specialist, Other , Myrtle Point, Oregon