Transitional Care Nurse Practitioner (IL RBE)

Company: Oak Street Health
Location: Chicago
Posted on: September 3, 2024

Job Description:

Company: Oak Street HealthTitle: Transitional Care Nurse PractitionerLocation: ILRole DescriptionThe Advanced Practice Provider, Transitions delivers high-touch, high-quality care to the highest risk patients attributed to Oak Street Health and the Oak Street Health Risk-Bearing Entity (RBE) within their homes. Our APPs lead a cohesive team of Oakies in delivering in-home support and care following adverse events, which include inpatient admissions. APPs in a defined territory collaborate continuously with other team members for post-discharge follow up care coordination, medication reconciliation, and social services follow up. Provider teams enjoy easy access to clinical support from peers and medical directors and use best in class population health data to support patients when they need it most.Core ResponsibilitiesProvide post-discharge support according to defined pathways within the patient's homeDevelop care plans and individualize goals of care with patient, their families, and their providersOptimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challengesCollaborate with Transitional Care Managers, home health, social workers, hospitals, SNFs, and specialistsStructure and prioritize scheduling based on clinical complexity for both new and routine patientsRecognize, diagnose, and manage both acute and chronic medical conditions in order to prevent destabilization and readmissionsProvide after-hours and weekend call support, shared with other in state providersFacilitate and conduct goals of care and advance care planning discussions with patients and familiesAssess and evaluate family / caregiver needs and limitationsTeach patients, caregivers, and others about their health conditionsAccurate and timely documentation of patient encounters in Oak Streetas electronic medical recordChampion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident ReportingOther duties, as assignedWhat are we looking forGenuine passion for reaching vulnerable patientsStrong clinical skills focused on older adults with complex disease statesComfort navigating visits in patient homesDemonstrated ability to collaborate effectively in a team settingWillingness to learn and be accountable for visit documentation and workflowsExcellent communication, follow-up, teamwork, and problem-solving skillsDesire to be a part of a fast-paced, innovative, quality-driven organizationRequired QualificationsHave an active, non-probationary state medical license, including US work authorization, if applicable1+ years APN experience, preferably with a Medicare populationExperience in home-based care (as RN or APP) preferredFlexibility to travel throughout service areaElectronic Medical Record experienceComputer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not requiredWhat does being Oaky look like?Radiating positive energyAssuming good intentionsCreating an unmatched patient experienceDriving clinical excellenceTaking ownership and delivering resultsBeing relentlessly determinedWhy Oak Street Health?Oak Street Health is on a mission to Rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient's communities, and focused on the quality of care over volume of services. We're an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.Oak Street Health Benefits:Mission-focused career impacting change and measurably improving health outcomes for Medicare patientsPaid vacation, sick time, and investment/retirement 401K match optionsHealth insurance, vision, and dental benefitsOpportunities for leadership development and continuing education stipendsNew centers and flexible work environmentsOpportunities for high levels of responsibility and rapid advancementOak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-healthby Jobble

Keywords: Oak Street Health, Chicago , Transitional Care Nurse Practitioner (IL RBE), Healthcare , Chicago, Illinois