Regional Triage Nurse

Overview

We are seeking a Registered Nurse to service patients throughout the Brunswick area. The Nurse Case Manager is a critical part of the patient’s care team who will visit patients, coordinate with providers, and initiate telemedicine visits. Travel to patients’ homes and facilities to evaluate patients is required, with care provided in adherence to all applicable laws, regulations, and policies within the scope of practice.

• Manage a full patient load in the designated region based on priority.
• Perform visits in homes and facilities (ALF and ILF) within the service area; travel is required daily.
• Track schedules (examples: 7 on/7 off; Pittman Schedule 2 on/2 off/3 on); 8-hour shifts Monday–Friday (8am–5pm).
• Coordinate with care teams to obtain and review medical records from primary providers and specialists.
• Complete patient consents and enroll patients in Care Management if eligible.
• Initiate and document a Care Management Plan of Care when appropriate.
• Capture diagnoses at the highest specificity and address gaps; ensure they are accepted.
• Complete annual wellness visits (AWV), cognitive impairment screenings, and Social Determinants of Health (SDoH) assessments or screenings.
• Complete advance care planning (ACPs) as reviewed with the patient by the provider.
• Evaluate for home health, hospice, palliative care, or consults with the appropriate division.
• Evaluate for RPM devices, resources, or tools to improve quality of life.
• Communicate and coordinate care; reconcile prescribed and OTC medications, vitamins, supplements, and other treatments.
• Provide post-discharge education and evaluate for adaptive equipment or DME; assess safety of the home environment.
• Document and log Care Management activities; collaborate with the care team to keep care plans up to date.

• Must be a licensed nurse (Registered nurse preferred); license in good standing with the appropriate board/issuer.
• Minimum three (3) years of clinical experience preferred.
• Experience in community settings preferred.
• Proven ability to communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
• Strong written and verbal skills; basic computer knowledge.
• Ability to manage and demonstrate effective leadership skills; ability to foster a cooperative work environment.
• Team player with ability to manage multiple responsibilities and sound judgment.
• Must be able to work flexible hours and travel between offices and facilities; must be a licensed driver with a properly insured automobile in good working order.

• Brunswick area

Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.