Care Coach Connect Registered Nurse Field Based Plano, TX

Overview

Well Med, part of the Optum family of businesses, is seeking a Care Coach Connect Registered Nurse to join our team in Plano, TX. Optum is a clinician‑led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone. At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. You’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim.

Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country.

• Conduct medical home visits on established Care Coach Connect patients performing a hands‑on exam at each visit.
• Conduct 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.
• Provide 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.
• Perform procedures such as wound care and dressing change, phlebotomy, and injections (B12, vaccines).
• Conduct an advanced care discussion with a patient and their family and properly document their wishes in the electronic medical record. Consult and educate 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.
• Initiate 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.
• Provide ongoing evaluation of the patient and family/caregiver response to care and recommend alteration of the plan when necessary.
• Attend the interdisciplinary meeting and is a crucial and vocal member of the team.
• Solve 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. Apply individual reasoning to the solution of a problem, devising or modifying processes and writing procedures.
• Conduct telephonic nursing follow‑up and case management when necessary.
• Serve as a resource or consultant for LVN/MA.
• Attend educational offerings to keep abreast of chronic medical conditions and comply with licensing requirements.
• Establish a trusting relationship with identified patients, caregivers, clinic staff members and providers.
• Collaborate with the providers to recommend policies, procedures and standards which affect the care of the Care Coach Connect patient.
• Exhibit professionalism and be courteous with all patients, physicians and co‑workers.
• Inform the provider of patient’s needs and outcomes of interventions as per standards.
• Follow Care Coach Connect providers’ orders regarding the scope and frequency of services needed based on acuity and patient/family needs.
• Coordinate all patient/family services and prioritize needs with the members of the interdisciplinary team.
• Document in the electronic health record progress toward established goals as per standards.
• Use the case management approach and refer to other services as needed.
• Maintain a patient case load, daily visits and point‑of‑care documentation levels as per standards.
• Perform all other related nursing duties as assigned.

• Registered Nurse with a current license to practice in the state of employment.
• Current BLS certification or must obtain certification within 30 days of employment hire date.
• 3+ years of clinical experience as a Registered Nurse in a home health,…