Resource RN - Pop Health - NC - REMOTE

This is a 100% remote position. Candidates must hold an active North Carolina RN license or a Compact RN license that permits practice in North Carolina. Familiarity with North Carolina communities, healthcare resources, and the populations served is preferred.

• Outreach to members while admitted inpatient or after inpatient or emergency department discharge to conduct focused transitions of care assessments.
• Outreach to case managers for members that are admitted inpatient to assist with discharge planning as needed.
• Complete self-efficacy and condition-specific screeners including behavioral health tools like PHQ-9, GAD-7, AUDIT, or DAST-10, to identify members requiring behavioral health programming.
• Conduct in-person clinical exams if appropriate and collaborate with care team members to determine if a different intensity program placement is needed.
• Conduct comprehensive medication reconciliation and address contracted and company-prioritized quality gaps, ensuring proper chart documentation and appropriate ICD or CPT coding as evidence of gap closure.
• Triage referrals from the Population Health Partner for short term clinical interventions and chronic disease management.
• Meet members in various community settings such as homes,shelters, or hospitals, serving as an extender of care team providers and performing tasks like administering injections, monitoring vital signs, and in-home medication reconciliation.
• Review charts and data signals for potential transition to higher level of complex care management.
• Facilitate follow ups and hand offs to care team as needed.
• Utilize care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate effectively with the team, members, and community resources.

• Timely outreach to members and hospital case managers for transitions of care support.
• Completion of focused transitions of care assessments, ensuring accurate medication reconciliation and follow up visits are scheduled.
• Identification and timely escalation of members requiring higher-intensity programs or behavioral health interventions.
• Completion of assigned queue tasks within established timelines.
• Efficient management of multiple short-term clinical assignments without compromising quality.
• Effective communication and collaboration with care team members, Population Health Partners, and community providers.

Professional Experience & Knowledge

Education:

Graduate of an accredited school of nursing (R.N.)

Experience:

3+ years of experience

Problem Solving:
Strong critical thinker with sound clinical judgment who makes complex decisions independently and knows when to collaborate. Identifies system barriers to care and develops creative, practical solutions. Demonstrates a growth mindset and openness to innovative approaches to improve outcomes.

Communication:
Strong written and verbal communicator across phone, text, virtual, and in-person settings. Comfortable using technology to engage members remotely. Applies Motivational Interviewing and Trauma-Informed Care principles to build trust. Effectively translates clinical information for non-clinical audiences and actively listens to understand and address needs.

Member Advocate

Mission Driven:
Balances competing priorities by choosing the path that best aligns with service to members and inclusive processes.

Compassionate Care:
Identifies and responds to member needs proactively and suggests improvements that enhance the member experience.

Business Acumen:
Applies understanding of government-funded care to make better recommendations and improve processes.