- Consistently exhibits behavior and communication skills that demonstrate Tandigm Health’s commitment to superior customer service, including quality, care, and concern for all internal and external customers.
- Conducts initial home visits and collaborates with the Nurse Care Manager to provide complex care planning for high risk patients in the CCM program.
- Works directly with the Nurse Care Manager to incorporate insights drawn from health assessments and recommends changes to the care plan, as needed.
- Conducts nursing assessments of patients to determine their overall health status and provides clinical recommendations to the Nurse Care Manager to inform the development of care plans.
- Delivers routine health assessments, home evaluations, and elements of care plans to patients when clinical input is required and telephonic assessments are insufficient; this can include collecting vitals, conducting regular health check-ins, etc.
- Evaluates patients’ well-being and general health status during health assessments to determine how they are progressing against their care plan.
- The frequency and schedule of patient home visits are determined in consultation with NCMs and supported by Clinical Coordinators.
- Promotes patient self-management strategies for improving clinical outcomes; this can include educating patients on their disease and medication so they can recognize early symptoms and better understand how, when, and where to access care.
- Partners with Nurse Practitioners to co-manage, coordinate, and deliver their respective elements of the patient care plans.
- Coordinates with other CCM members (e.g., Nurse Care Manager, Social Worker, BH Specialist, Pharmacist) to ensure all factors
impacting the patient’s clinical well-being are being addressed through the care plan.
- Uses, protects, and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability
and Accountability Act (HIPAA) standards.
- Performs additional duties, as assigned.
- Completion of a Bachelor of Science in Nursing (BSN) with;
- Minimum 5 years of relevant clinical experience in a hospital, clinical, or home care setting is required
- Management of patients with complex medical conditions required
Knowledge, Skills, Abilities
- Ability to communicate clearly and efficiently with patients, families, and PCP staff
- Ability to communicate clearly, serve as a resource to, and partner seamlessly with, all members of the Complex Care Management team
- Ability to monitor a patient’s health, identify key clinical information, and offer timely updates that inform the patient’s care plan
- Language skills consistent with the predominant needs of the population
- Current and unrestricted Pennsylvania RN license in good standing
- Basic Life Support for Healthcare providers (AHA) or CPR/AED for the Professional Rescuer (American Red Cross)
- Driver’s License in good standing, with ability to travel within the Philadelphia, PA territory (Bucks, Montgomery, Chester, Delaware & Philadelphia Counties) as needed
- Ability and means to travel on a flexible schedule as needed; proof of liability and property damage insurance on vehicle used is
Physical Requirements in Accordance with ADA
Carrying/Lifting: Occasional, 0-25 lbs.
Standing: Frequent, up to 6 hours per day
Sitting: Frequent, up to 6 hours per day
Walking: Frequent, up to 6 hours per day
Repetitive Motion: Keyboard activity, telephone use, writing, reaching, grasping, pushing, pulling
Visual Acuity: Ability to view computer monitors and read newsprint, with or without corrective lenses
Environmental Exposure: None
Jump start your career by clicking the link below to apply.
Tandigm Health is an Equal Opportunity Employer (EOE)