Care Coach Connect Registered Nurse Field Based - Plano, TX

Explore opportunities with WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will be part of a team who shares your passion for helping people achieve improved health outcomes. Explore rewarding opportunities for physicians, clinical staff and non-patient-facing roles. Join us and discover the meaning behind Caring. Connecting. Growing together.   The Care Coach Connect RN coordinates care and provides initial ongoing nursing assessment of the patient and family needs and coordination of the patient's plan of care with interdisciplinary team members and the Care Coach Connect supervising clinician. The CCC Registered Nurse is responsible for performing 90% home visits and 10% telephonic case management.

Conducts medical home visits on established Care Coach Connect patients performing a hands on exam at each visit Conducts urgent/acute visits on established Care Coach Connect patients with the goal of keeping the patient out of the hospital in order to receive the best medical care at home Provides ongoing assessments of the impact of life-limiting and/or chronic illness(es) on the patient's physical, functional, psychosocial and environmental needs Assess for caregiver burnout, and provide community resources when appropriate Implement the individualized plan of care and recommend revisions to the plan as necessary Ability to perform procedures, to include, but not limited to: a. Wound care and dressing change b. Phlebotomy c. injection (B12, vaccines) Ability to conduct an advanced care discussion with a patient and their family and properly document their wishes in the electronic medical record. Consults and educates the patient/family and other caregivers regarding the disease process, pain and symptom management, end of life care and processes for dealing with issues of ethical concern Initiates appropriate preventive and rehabilitative nursing procedures when appropriate Ensure continual assessment of patient and family needs from admission to Care Coach Connect throughout the course of care Provides ongoing evaluation of the patient and family/caregiver response to care, and recommends alteration of the plan when necessary. 12. Attends the interdisciplinary meeting and is a crucial and vocal member of the team Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. Decision making is usually based on prior practice or policy, with some interpretation. Applies individual reasoning to the solution of a problem devising or modifying processes and writing procedures Conducts telephonic nursing follow up and case management when necessary Serves as a resource or consultant for LVN/MA Attends educational offerings to keep abreast of chronic medical conditions and complies with licensing requirements Establishes a trusting relationship with identified patients, caregivers, clinic staff members and Providers Collaborates with the providers to recommend policies, procedures and standards which affect the care of the Care Coach Connect Patient Exhibits professionalism and is courteous with all patients, physicians and co-workers Informs the provider of patient's needs and outcomes of interventions as per standards Follows Care Coach Connect providers' orders regarding the scope and frequency of services needed based on acuity and patient/family needs Coordinates all patient/family services and prioritization of needs with the members of the interdisciplinary team Documents in the electronic health record progress toward established goals as per standards Uses the case management approach and refers to other services as needed Maintains a patient case load, daily visits and point of care documentation levels as per standards Performs all other related nursing duties as assigned In 2011, WellMed partnered with Optum to provide care to patients across Texas and