Summary

Position sees Medicare Annual Wellness Visit patients to help close Quality measure gaps to generate Medicare Shared Savings.  Revenue captured from this visit paid by Medicare is approximate $175 per visit.  The position assists with seeing these patients for the physicians to allow physicians to see patients with more complex issues.

Role will see up to seven patients per day in Primary Care clinics and specialty clinics/ 5 days a week.  The visit is solely focused on patient education and disease prevention.  This is the one visit out of any other visit that impacts multiple quality measures, such as depression screening, falls screening, hypertension, diabetes, advanced care planning and other measures.  This is also a CommonSpirit Health national measure, as well as a Baylor College of Medicine initiative to complete a minimum of 2,000 visits per year.

The position is a traveling position to clinics in Medical Center.  The ideal candidate will have five years of experience as a Registered Nurse and experience in adult patient care.

Job Duties

• Performs initial assessment of patients. Assess patient needs for healthcare resources based on medical condition, patient resources, and potential barriers to optimal progression through the healthcare system.
• Functions as a resource to clinical staff regarding patient assessment and plan of care or performs patient assessment and develops a plan of care to assure consistent and appropriate care is provided in a patient focused manner.
• Facilitates discharge planning efforts through early identification of high risk patients. Manages each patient's transition through the system and transfers accountability to the appropriate person upon entry into another clinical service. 
• Serves as a patient advocate to assure patient education is completed.
• Plans and implements (through multi-disciplinary meetings, messaging and conversations with the care team, and with patient or family) strategies to reduce resource consumption, and achieve high quality positive patient outcomes. 
• Evaluates and measures outcomes in order to continuously improve practice and to enhance outcomes.
• Identifies changes in patients’ clinical progression or needs to assure continuity of care. The following may be assessed to determine needs: medical, rehabilitative, psychosocial and physical needs. 
• Assures timely referral to other services to facilitate ongoing care needs of patient.
• Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient’s and family’s ability to make informed decisions.
• Coordinates the provision of social and other support services to patients, families, and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Utilizes appropriate resources in cases that present ethical dilemmas.
• Communicates with payers to facilitate the patient’s effective and efficient movement through the healthcare system.
• Completes all aspects of the Nurse, Registered II (BA 12) Job Description as required to support patient care for the assigned population.
• Understands and adheres to the college Medical Center compliance standards as they appear in the Corporate Compliance Policy, Code of Conduct, and Conflict of Interest Policy.
• Keeps abreast of all pertinent federal, state, and the college regulations, laws, and policies as they presently exist and as they change or are modified.
• Ensures that the staff are trained and evaluated on their knowledge of and adherence to compliance policies and procedures specific to their jobs.

Minimum Qualifications

• Bachelor's degree in Nursing.
• Four years of relevant experience.
• Current license as a Registered Nurse (RN) by the State of Texas Board of Nursing.
   

Preferred Qualifications

• Eligibility or Certification in Case Management by the Texas Department of State Health Services (DSHS).
• Basic Life Support Certification.