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