Registered Nurse – Home Health

Position Summary Briefly describe the overall purpose of this position - why does it exist and how does it contribute to the overall organization? The Community Registered Nurse ensures that a defined panel of enrolled individuals receives the highest quality, primary and community based skilled care within the context of a member centric individualized plan of care. The Community Registered Nurse has the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of CCA's members by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, LTSS and home based community services utilization, , goals of care conversations, advance care planning, providing skilled nursing services that allow for optimal self-management, and supporting palliative and end of life care. The Community Primary Nurse will maintain close contact and collaboration with the member's network PCP, providers, and specialists in the development and implementation of clinical plans of care. As an integral part of an Interprofessional Care Team and based on the fluctuating needs of the defined panel of members, the Community Registered Nurse will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members' Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs. The Community Registered Nurse is supported by a fully staffed interprofessional care team that has, at its core, a Care Partner who is accountable for all aspects of care management and care coordination. The Community Registered Nurse collaborates with the entire care team, and keeps the Care Partner well informed on members', providing critical clinical information that helps drive the overall ICP. The Community Registered Nurse will make adjustments to the ICP as indicated, identifying gaps and, in concert with the Care Partner, will leverage covered benefits to ensure that the right mix of services are in place to meet the member's unique needs. This position requires in person visits to members in their homes and will support members across various locations The Community RN reports to the team Clinical Manager