Required skills & experience:

•Active, unrestricted Registered Nurse license in the state in which you are seeking employment

•You have 3+ years of experience providing clinical services to Pediatric, Adult and Geriatric individuals with co-occurring chronic medical and behavioral health conditions (***70% of patients will be pediatrics, so RN needs to have experience treating Peds and all ages)

•Work a full-time 40 hour week, Monday-Friday 9am to 5pm ET with one late evening a week, consisting of team meetings, case conference, supervision, and field-based independent clinical and co-visits.

•Experience and comfort working within an interdisciplinary care team, and specifically working alongside community health workers and care coordination team members

•Familiarity and willingness to travel within your community (home-based member visits) and its healthcare systems (hospitals and rehab centers)

•Experience in transitions of care management, both in-person and virtual

•Experience as an active participant in continuous quality improvement projects within a provider setting

•Possess exceptional triage, coordination and clinical assessment skills

•70% of population treated will be pediatrics, so needs to have a background familiar with treating children and comfortable providing care for peds

•This model is Hub based, so not as much out in the field and more treating patients from Client Hubs.



What you need to know:

•You will work in a radically different model of healthcare

•Expect collaboration, shared-decision making, and partnership across clinical and non-clinical care team members, including our large team of Community Health Partners

•In addition to supporting your members in the community, you will be asked to support clinical operations in the hub on a rotating basis by having an in-person presence and working with providers as needed

•Co-manage a population living with complex medical and behavioral health conditions

•Collaborate on a panel of members assigned to your care team to provide, nursing clinical support, including transitional care, health maintenance, medication reconciliation & administration, chronic disease management and co-occurring psychiatric disorders

•Your work will take you into the community. You will meet with members in their homes, neighborhoods, at the point of hospital discharge and within the healthcare system. These visits can be done individually, or as co-visits with one of your care team members (i.e. Community Health Partners, Behavioral Health Specialists, Nurse Practitioners)

•Conduct several home visits in a given day, including scheduled and unscheduled episodic urgent member needs

•Provide ongoing clinical support to your panel of members in partnership with your interdisciplinary care team, prioritizing member visits based on their health needs

•Assess in-home safety and risks and implement evidence-based interventions and protocols for complex chronic conditions

•Assist members with medication reconciliation, medication administration & medication compliance