Guidewell Care Solutions Readmission Prevention RN-Pinellas Park GuideWell - Pinellas Park, FL

Company: GuideWell
Location: Pinellas Park
Posted on: January 13, 2022

Job Description:

Under the direction of the Readmission Prevention Manager, the Readmission Prevention RN will provide support to Florida Blue Medicare members who are at risk for readmission. FBM's Readmission Prevention team will outreach members during and post hospitalization, to assist them in overcoming major "barriers to care". This activity is done through a variety of methods such as home, facility or office visits, telephonic support and follow-up. The goal is to improve the health outcomes of these at risk members and reduce FBM's overall readmission rates.



Essential Functions

• 
  
• The essential functions listed represent the major duties of this role, additional duties may be assigned.
  
• Meet with members, (and/or their caregivers) who are at high risk for readmission, post discharge, in person, if at all possible, if not by phone, 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.
  
  ***Must reside in the Pinellas County area***
  Required Work Experience
  
  2+ years related work experience. Experience Details: Recent clinical and/or case experience
  Required Education
  
  High school diploma or GED
  Travel will begin to members in the January 2022 timeframe
  Required Licenses and Certifications
  
  RN - Registered Nurse - State Licensure And/Or Compact State Licensure Without Restriction Upon Hire
  
  CCM - Certified Case Manager 1 1/2 Yrs
  Additional Required Qualifications
  
  Current and valid state driver's license and current liability insurance coverage
  Preferred Education
  
  Bachelor's degree Nursing
  Preferred Licenses and Certifications
  
  CCM - Certified Case Manager Upon Hire
  Additional Preferred Qualifications
  
  Home care Experience Bilingual English/Spanish
  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. Occasionally
  
  We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.
  

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