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Gonzaba Medical Group

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High Risk Clinical RN

Open 31d

Summary: This nursing role focuses on improving quality of care /continuity of care and reducing utilization costs. HRN provides direct clinical care in the home for select GMG MC Patients. The focus is on high risk patients who have complex wounds, are high risk, and need complex treatment protocols. This nurse provides clear feedback in a timely basis to the Wound Care Specialist, PCP, and/or other pertinent providers on the case.

Duties:

  1. Provides clinical care to High Risk or high cost patients in their home, including: wound care, wound vacs, IV antibiotics, body systems check, safety checks, medication reconciliation, pt teaching, etc.
  2. Reports findings in a timely manner to the Wound Care Specialist, PCP, and/or other pertinent providers on the case.
  3. Documents findings same day in EMR. Documentation is clear, succinct and pertinent. Utilizes EMR functionality to enhance documentation, including ability to take pictures and incorporate in the note.
  4. Communicates clearly and effectively with other High Risk Nurses, Case Management, and other members of the Care Team. Works effectively with team to provide same day care to High Risk patients when the need arises.
  5. Organizes time, talents and supplies on hand wisely to see patients in the most efficient and effective manner. Triages to Home Health Agency when necessary and appropriate
  6. Informs patients when to expect visits. Confirm agreement.
  7. Follow daily Hospital Census Report searching for patients in need of High Risk Visiting Nurse visits.
  8. Ensures that patients have prompt Hospital Follow up appointments to help prevent readmission. Assess discharge status, level of understanding and compliance;
  9. Attends Patient Care Committee and High Risk Team meetings to identify special care needs defined during PCC and HR Mtgs.
  10. Exercise tact and courtesy when dealing with patients, visitors, physicians and co-workers.
  11. Maintains strictest member and company confidentiality.
  12. Ensures member health information is secured each day.
  13. Able to work efficiently under pressure.
  14. Other duties as assigned.
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