Market RN - California

The ConcertoCare Market Registered Nurse provides virtual clinical care and clinical navigation support for our patients to ensure they get the right care, in the right place, by the right person, and at the right time. Key activities include patient evaluation and management, clinical triage, patient and caregiver education, and support for care coordination in partnership with the provider and extended care team. This position reports to the Practice Manager with clinical oversight from the Medical Director. This is an ideal position for a registered nurse who seeks an opportunity for “top of license” clinical practice, enjoys a collaborative multidisciplinary team-based approach to care, and is excited to engage in developing and nurturing our innovative, value-based clinical model focused on caring for patients with complex needs who are inadequately served by traditional healthcare delivery systems. This exciting role allows you to deliver clinical care, virtually from your own home, with the support of clinical providers, community health workers, medical assistants, nurse case managers, clinical social workers, and clinical pharmacists. This position also affords professional development via dedicated clinical education programming and real-time support from our on-staff world-class experts in geriatric medicine, palliative care, geriatric psychiatry, clinical pharmacy, care management, and social determinants of health and health equity.

Provision of compassionate, individualized, and holistic patient care that aligns with our value-based care delivery model, reflects appropriate patient risk stratification, integrates with multidisciplinary team-based care, and identifies and addresses gaps in care. Delivery of exceptional clinical care, guidance, and education virtually with a focus on urgent needs for rising-risk patients and chronic condition management for high-risk patients. Emergent and urgent telephonic triage to ensure our patients receive the right care, in the right place, at the right time. Care coordination for acute needs and/or limited duration needs for patients who are not receiving formal transitions of care and/or longitudinal case management support. Development, implementation, and modification of individualized action plans for patients to improve clinical outcomes. Clinical supervision for licensed practical nurse (LPN) and/or medical assistant (MA) activities as requested. Accurate and timely documentation in the medical record of all patient care activities. Integration of clinical practice, data dashboards, and operational processes that support the achievement of company performance goals into daily clinical approaches and workflows. Promotion of and participation in patient engagement and experience initiatives and efforts. Active participation in care team huddles, operational huddles, organizational meetings, and clinical partnership meetings as requested including preparation and follow-up activities. Adherence to medical policies, protocols, criteria, and clinical guidelines to ensure best practices are maintained for clinically effective and efficient care delivery. Adherence to compliance policies, procedures, and standards of conduct including all applicable laws and regulations. Other market-specific duties as assigned.