Registered Nurse Case Manager | Field-Based
At UpStream, we are dedicated to promoting good health and empowering individuals to lead independent lives. As a trusted partner to primary care physicians, we offer effective and sustainable care options, focusing on seniors and those with chronic conditions. Our comprehensive solution allows physicians to prioritize patient care while our value-based care model ensures effective condition management.
We prioritize affordability and accessibility, collaborating with healthcare practices and clinics to reduce costs and enhance system efficiency. Through personalized care plans and innovative solutions, we strive to improve health outcomes and enable patients to live fulfilling, independent lives.
How you’ll help
UpStream’s Coordinating Registered Nurses (CRNs) work closely with patients and Interdisciplinary Clinical Team (ICT) members to support the ongoing and coordinated care of UpStream’s patient population. As an integral member of the ICT, the CRN moves between providing high quality care in patients homes and within a clinic setting to support the ongoing and coordinated care of UpStream’s patient population. You will serve as the clinical lead for a select patient population who meet predefined, health criteria. As the clinical lead for the patient, you'll work directly with each patient to co-create a patient Care Plan aimed at resolving and preventing critical events, controlling chronic conditions, decreasing avoidable hospital admissions (and readmissions), ensuring safe care transitions, and improving self-management skills.
CRN's contribute to UpStream’s patient-centric, emotionally-intelligent, and relationship-based culture. We seek individuals interested in positively contributing to this culture and growth. This position requires confidentiality, discretion, critical-thinking, and exceptional patient service.
What you’ll do
In conjunction with the primary care provider and in collaboration with an Interdisciplinary Clinical Team (ICT), the following key care management services are performed by the Registered Nurse. Each of these services has standardized protocols of delivery and documentation.
- Outreach and health promotion services that are offered in the patient’s home environment, in the primary care office or telephonically
- Comprehensive assessment with required EMR documentation
- Development and implementation of an individualized care plan based on the patients’ and clinicians’ goals of care.
- Disease management of high- risk chronic conditions.
- Coordination of referrals and transitions of care from one provider to another or from one care setting to another to include evaluation of need to escalate level of care setting.
- Medication reconciliation and adherence
- Implementation of PCP and ICT prescribed medical interventions, including but not limited to wound care, pharmacologic therapy, intravenous medication and fluid administration, respiratory treatments, and home phlebotomy
- Facilitation and/or procuring timely access to appointments and services required by patient
- Patient and family/caregiver education
- Evaluation of effectiveness of care plan with ICT and the Care & Quality Team together with the patient, evaluates baseline medical and psychosocial risks and creates individualized patient care/treatment plans to be carried out by transition care specialists, pharmacists, clinical medical assistants, care coordinators, and/or partners with primary care and specialties
- Evaluation of need for additional homebased diagnostic services
- Assesses patient/family abilities to self-engage and develops individualized patient/family education plan focused on development of self-management skills based on standard care protocols
- Advises/educates patient, family/caregiver on importance of medication adherence and helps facilitate the removal of adherence barriers
- Early identification of patients with special needs and facilitates integration of primary care with specialty and other services such as behavioral, social, and community services where appropriate
- Plans, develops, assesses, and evaluates care provided to specific patient populations and engages team of transitional care specialist(s) and care coordination to divide workload among team where appropriate
- Recommends alternative levels or modalities of care and ensures compliance with federal, state, and local requirements
- Advocates the completion of living wills and advance care planning and where appropriate begin palliative care consults
- Develops and collects data; analyzes utilization of health care resources, including interpretation and application to case load decision making where appropriate
- Performs analysis of the effectiveness and appropriateness of patient care plan; and modifies care plan based on assessment and evaluation.
- Communicates clear, complete, and accurate documentation in a health record to ensure that all those involved in a client’s care have access to information upon which to plan and evaluate their interventions
- Updates plan of are timely to ensure all members of the care team have timely information regarding the patients’ status
- Leads team pre-visit planning activities including inpatient post-discharge activities and participates in daily huddles of ambulatory practice(s) where assigned
Experience and skills you’ll need
- Registered Nurse with bachelor’s degree or equivalent with a minimum of 3 years direct practice experience
- Must have an active license in the state of North Carolina
- Experience in critical care, emergency care, or home health care highly preferred
- Previous experience as a Registered Nurse, Care Manager, or in Acute Care Management
- Understanding of population health management preferred
- Excellent patient service skills
- Ability to maintain a positive attitude and personally connect with patients, caregivers, and fellow team members
- Must be able to work independently and interdependently within a team
- Developed analytical and critical thinking skills
- Excellent written and verbal communication skills
- Strong attention to detail
- Must be self-motivated and adaptable to changing processes
- A desire to be part of something bigger than oneself
- Experience using multiple electronic medical records
- Adept at using Microsoft 365, Word, Excel, and Outlook
What a Day In the Life Looks Like
- On average 70% field based, and 30% clinic based
- Daily schedule in the Electronic Medical Record
- Dayshift (approximately 8am - 5pm Monday - Friday)
- UpStream Car provided for work purposes
- UpStream uniform supplied
- Weekly education and professional development
At UpStream we offer a range of benefits to ensure our employees are taken care of. Our health insurance plans through United Health Care include FSA and HSA options, and we also offer dental, vision, life, and accident coverage through Guardian. We immediately match contributions to our 401k plan, which includes both Roth and Traditional options. In addition, we provide financial perks and rewards through BenefitHub, and free access to EAP services through WorkLifeMatters. Our employees also enjoy generous PTO and paid holidays.
We value diversity and promote equal opportunities for all. As an equal opportunity employer, we do not discriminate against applicants based on their race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. All qualified candidates are encouraged to apply.