Registered Nurse

Why Join Grace at Home?

Grace at Home is a provider-led, community-based health and care partner dedicated to improving the health and well-being of those who need care the most, with a deep commitment to high-needs, urban and rural communities. Our local physicians, nurses, and caregivers work together to serve people and the communities they live in, beyond just treating symptoms. We remove barriers by delivering personalized care as close to home as possible, often in-home, because we know a deep understanding of our patient s race, culture, and environment is critical to delivering improved health outcomes.

By empowering patients, providers, and caregivers with the support they need, we strive to make health and care a reality not a burden every single day. Join us in creating a better way to care.

The Grace at Home program is designed to provide additional support to our patients by providing an integrated level of equitable value-based medical care and social support in the comfort of where our members call home. This program is offered to eligible health plan patients with the primary goal of mitigating adverse health complications, unmanaged disease progression and ultimately avoid unnecessary hospitalization that can occur when timely clinical interventions are not provided or are not accessible.

In this role, you'll collaborate closely with a multi-disciplinary clinical team to deliver high-quality, personalized care in both a home-based and telehealth setting. The ideal candidate is committed to providing longitudinal care to build meaningful patient relationships, improving patient outcomes, and eager to make a meaningful impact in underserved communities.

Overview

The RN reports to the Clinical Manager or designee, with accountability for providing strategy, judgment, organization, and evidenced-based analysis to influence decisions, and directly to meet Grace at Home s requirements. They should embody Grace at Home s core values, including, Trusted, Empathetic, Committed, Humble, Creative and Community-Minded. At Grace at Home, we don t have patients or customers we have Family Members.

Grace at Home model is designed for member engagement of the high-risk population with an emphasis on event-driven care management leveraging care pathways and evidenced based guidelines tailored to black and brown populations. Care Management includes assessing healthcare needs, identifying problems and opportunities for improvement, implementing Nursing Care Plans, managing the patient care transition process, assisting patients throughout care episodes, coordinating, and facilitating care for patients with complex, chronic medical and mental health conditions, providing disease education, and promoting evidence-based healthcare services.

The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for patients/families struggling with chronic disease management. It is critical that care management be done in conjunction and always with the Caregiver, including their and the member s signoff. Conducting Caregiver assessments are also part of the Care Management process.

Primary Responsibilities

The RN will have the following responsibilities:

The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for Grace at Home s members/families struggling with chronic disease management.

Works with member and care team to conduct appropriate assessments that result in a nursing care plan prioritized by the patient and caregivers.

Conducts in-home or tele-health assessments, as directed by the model and leadership

Track nursing care plan outcomes, interventions, and continue to reassess the patient's needs as appropriate.

Utilizes care pathway templates by condition with risk levels and member actions by event type.

Deploys Remote Patient Monitoring and Patient Self Reporting for High-Risk Chronic Conditions.

Conducts transition of care visits both virtually and in-home to ensure smooth transition from an acute care setting to home.

Provide care coordination for Grace at Home s Family Members including patient navigation,…