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.

The RN reports to the Director/VP of Clinical Operations or designee, with accountability for providing strategy, judgment, organization, and evidenced‑based analysis to influence decisions, and directly to meet Care at Home’s requirements. They should embody Care 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.

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, chronic disease management/education and interdisciplinary collaboration while complying with department policies and procedures and other contractual requirements.
• Engage members in taking a proactive role for managing their health, medications, treatment and mental health needs, and follow‑up appointments and refer patients to the appropriate community‑based organizations or other programs.
• Follow evidence‑based guidelines to facilitate closure of gaps in care and encourage and use of in‑network services if appropriate and determine when in‑home services are needed and ordered.
• Use the electronic medical record or clinical management platform to conduct care coordination activities and comply with associated policies and procedures including those for workflow and consistent documentation.
• Participate in team‑based rounds to support and contribute to ongoing program design and development as lessons are learned from the field and process improvement work performed within the department.
• Demonstrates an ability to identify and shift priorities within work assignment to effectively manage patient care load.
• Perform other job‑related duties as assigned.

The RN will have the following duties:

• Leadership
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  The RN will lead in defining and executing strategies and solutions to create business value in the clinical practice, including working with their team to…