Are you ready to disrupt healthcare in the greater Philadelphia, PA area? Jump start your career & disrupt at Tandigm !
Tandigm Health, LLC is a value based population health organization. We engage our physician network by aligning economics and rewarding them for the value of the care they provide rather than for the volume of services. We enable our physicians with innovative tools, actionable data, expert training and education, and clinical delivery support. We empower our physicians by building community-oriented care delivery systems that facilitate collaboration across the continuum of care.
At Tandigm you will find a culture where all Teammates have the opportunity to collaborate in an energized, multi-disciplinary work environment focused on improving patient outcomes and enabling our staff to do some of the most rewarding work of their careers.
The Field-Based Nurse is responsible for conducting clinical visits with Complex Care Management (CCM) patients who require home visits within the NE Philly/Montgomery County, PA territory. The Field-Based Nurse conducts nursing assessments to determine clinical status and patient needs, contributes to the patient care plan, and collaborates with the Nurse Care Manager to establish the frequency of home visits.
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.
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 required