Florida Blue
2+ yearsā experience recent clinical acute, home care and/or case management experience Current Florida RN - Registered Nurse Licensure And/or Compact State Licensure Without Restriction Hands-on experience with Microsoft suite of products, including Word, Outlook, PowerPoint, etc., as well as navigating through multiple systems such as electronic medical records Ability to drive your own vehicle to and from home assessment visits, and/or in clinical settings, within Palm Beach County (West Palm Beach and surrounding areas), FL approximately 20-40% of work time Current and valid state driver's license Associateās degree in nursing What is Preferred: CCM - Certified Case Manager Certification Home care Experience Bilingual English/Spanish Bachelorās degree in nursing General Physical Demands Medium work: Exerting up to 50 pounds of force occasionally and/or up to 20 pounds of force frequently to move objects. Physical/Environmental Activities: Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Frequently May be exposed to outdoor weather conditions of cold, heat, wet, and humidity. Occasionally Must be able to ascend and descend ladders, stairs, or other equipment.
Meet with members, (and/or their caregivers) who are at high risk for readmission, post discharge, in person preferrably, within 2 business days of discharge. Perform an assessment of members current health status, including potential knowledge deficits, environment, care giver(s) and others supports, creating a care plan identifying problems, goals and interventions, based on member's responses, conditions, needs and priorities, as appropriate. Conduct Comprehensive Medication Reconciliation process, including education, identification of potential medication concerns, document and address any possible issues with the ordering physician, pharmacy, etc. and provide CMR report to PCP Validate the initiation of planned care and services, reinforce understanding of discharge instructions utilizing teach back methods, answer questions as appropriate and address concerns. Coordinate/assign necessary interventions including any available community resources, enhanced benefits or flex benefit to overcome potential barriers to care, e.g. meals, transportation, etc. Facilitate appropriate practitioner office follow-up visit within 7-14 days of discharge. Follow-up with member and practitioner to confirm appointment was kept. Provide continuing telephonic support/follow up for at least 30 days post facility discharge.
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