Homebound Outreach & Quality Nurse / RN - Full Time

East Liberty Family Health Care Center; Pittsburgh (Allegheny County); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Medical

Dental

Vision

Life Insurance

Job summary

East Liberty Family Health Care Center is seeking a Homebound Outreach and Quality Nurse to provide nursing services to homebound patients and telephonic case management for clients with multiple chronic conditions. Bilingual English/Spanish candidates are strongly encouraged to apply.

This full-time role involves home visits, vital signs, specimen collection, medication management, and documentation in the EMR. Experience in chronic care, care coordination, and CMS programs is a plus.

Qualifications

• RN degree and current State Nursing Licensure.
• 3 years Home Care experience required.
• Geriatric nursing experience and MD office experience preferred.
• Valid Driver's License, Insurance and ability to commute to patient homes for visits.
• Knowledge of Electronic Medical Records documentation and management (eCW knowledge a plus).
• Working knowledge of CMS Chronic Care Management, community-based resources are a plus.

Responsibilities

• Screen physician referrals to the Homebound Program. Evaluate the referral based on program description and patient's need.
• Screen patient charts and update demographics including consents, sliding fee scale, contacts and insurance
• Evaluate patient's ongoing need for Homebound services based on program description.
• Discharge patients from the Homebound program according to discharge criteria outlined in the program description.
• Learn and implement the Chronic Care Management Program for ELFHCC Clients and track time.
• Develop care plans and goals for clients and follow appropriately using the Chronic Care Module.
• Visits patients in their home, take and record vital signs, obtain specimens, manage medications and perform laboratory testing per standing orders. Document results in the EMR in a timely manner.
• Assist with monitoring and scheduling TCM (Transitional Care Management) patients.
• Triage and respond to phone messages according to phone protocols. Document all calls before the end of the day.
• Monitor practice performance according to HRSA UDS, Patient Centered Medical Home and Health Plan quality standards, including programs for unconfirmed diagnosis codes and quality measures/gaps in care.
• Use reports available within the EMR as well as information obtained from Health Plans to identify patients that are overdue for preventative screenings.
• Perform chart reviews and audits (HRSA UDS, ELFHCC Peer Review, HEDIS, Health Plans, etc.).
• Assist in the preparation of reports for the QI/QA Committee, Leadership Committee, Practitioners and Nursing Staff meetings.

Skills

RN license

Home care

Geriatric care

EMR (eCW)

Bilingual English/Spanish

Education

RN degree

Tools

eCW EMR

Job description

Are you driven to serve the community by helping those with barriers to healthcare services receive the care that they need? Are you motivated to work in a fast‑paced community health care center that operates with a holistic approach to patient care? Do you want to be on a team that shares a passion and commitment to make a difference in the lives of others? If your answers are "yes," we want to hear from you!

We are a faith‑based Federally Qualified Health Care Center that serves multiple communities in the East‑End section of Pittsburgh, PA. Our mission is to provide quality health care to those who are underserved, underinsured and uninsured. Please visit www.elfhcc.com to learn more about our growing practice!

We are looking for a Homebound Outreach and Quality Nurse to join our team! This role will provide nursing services to our Homebound patients and telephonic case management for patients with multiple chronic conditions. Qualified candidates who are bilingual in English/Spanish are strongly encouraged to apply.

• COVID and influenza vaccines are required**

Please visit www.elfhcc.com for more information about our company and its mission to provide quality care to all. Position is full time at 40 hours per week. Qualified candidates who are bilingual in Spanish and English are encouraged to apply.

Qualifications

• RN degree and current State Nursing Licensure.
• 3 years Home Care experience required.
• Geriatric nursing experience and MD office experience preferred; Behavioral Health experience is a plus.
• Valid Driver's License, Insurance and ability to commute to patient homes for visits.
• Knowledge of Electronic Medical Records documentation and management (eCW knowledge a plus).
• Working knowledge of CMS Chronic Care Management, community‑based resources are a plus.

Key Job Responsibilities

• Screen physician referrals to the Homebound Program. Evaluate the referral based on program description and patient's need.
• Screen patient charts and update demographics including consents, sliding fee scale, contacts and insurance
• Evaluate patient's ongoing need for Homebound services based on program description.
• Discharge patients from the Homebound program according to discharge criteria outlined in the program description.
• Learn and implement the Chronic Care Management Program for ELFHCC Clients and track time.
• Develop care plans and goals for clients and follow appropriately using the Chronic Care Module.
• Visits patients in their home, take and record vital signs, obtain specimens, manage medications and perform laboratory testing per standing orders. Document results in the EMR in a timely manner.
• Assist with monitoring and scheduling TCM (Transitional Care Management) patients.
• Triage and respond to phone messages according to phone protocols. Document all calls before the end of the day.
• Monitor practice performance according to HRSA UDS, Patient Centered Medical Home and Health Plan quality standards, including programs for unconfirmed diagnosis codes and quality measures/gaps in care.
• Use reports available within the EMR as well as information obtained from Health Plans to identify patients that are overdue for preventative screenings.
• Perform chart reviews and audits (HRSA UDS, ELFHCC Peer Review, HEDIS, Health Plans, etc.).
• Assist in the preparation of reports for the QI/QA Committee, Leadership Committee, Practitioners and Nursing Staff meetings.

Must have a desire to serve the underserved in the East Liberty/Lincoln‑Lemington areas of Pittsburgh.

Compensation

Salary commensurate with education and experience.

Benefits

• Medical
• Dental
• Vision
• Life Insurance