Clinical Nurse Specialist Rn

The Clinical Nurse Specialist RN is an advanced practice nurse position. This position will manage and coordinate the care of a case load of Medicare beneficiaries who have either had a recent inpatient hospitalization, are in a skill nursing facility, have multiple ER visits within the last 12 months, or have complex chronic conditions and social determinants of health risk factors. The position serves as educator, patient outcome manager, clinical care consultant, and case manager. In this position the Clinical Nurse Specialist reports to the ABC Network Medical Director for clinical guidance. The Clinical Nurse Specialist is expected to practice at the top of their nursing clinical expertise to assess Medicare beneficiary risk factors work with primary care team and clinical specialists to assure the beneficiary get timely care and need support services include addressing any barriers to care. This position is considered a key contributor to the ABC Network care management of Medicare beneficiaries.
This position requires that you reside in or are willing to relocate to Southern Arizona.  This position requires some travel.
Essential Duties:

1. Management of a case load to Medicare Beneficiaries that have had an acute episode and/or had multiple chronic condition and/or complex care needs:
2. Follows protocols and clinical guidelines under the supervision of the Medical Director
3. Work with Medicare beneficiaries to support their compliance with, and adherence to, prescribed treatments.
4. As necessary arranges for wound care / ulcer care / removal of sutures, or assistive services for home bound Medicare beneficiaries.
5. Arranges for required mental health, social services, and/or community support services to address in social determinant of health barriers.
6. Initiate transition of care directing community health workers to assist beneficiaries from hospital or skill nursing facility to home or skilled nursing facility to hospice.
7. Coordinates the Medicare beneficiary discharge planning with hospital staff.
8. Reviews health risk assessments and SDOH assessments and communicates chronic and acute care conditions to primary care team.
9. Promotes health and wellness and works with Medicare beneficiaries to assure the receive their annual wellness visit.
10. Coordinates Medicare beneficiary care with specialists and other clinical services exchanging patient information and assuring beneficiary’s PCP team receives specialist clinical consultation and treatment information.  
11. Works with community health workers to direct and supervise them completing health and SDOH assessments and perform home safety assessments.
12. Develops individual care plans in collaboration with assigned Medicare beneficiaries and/or care givers.

Qualification and Experience

1. Five years’ experience working with Medicare beneficiaries in a similar role at for a ACO, hospital, or healthcare delivery system.
2. Minimum of master’s degree in nursing.
3. Must be an Arizona Licensed RN
4. Strong problem-solving skills.
5. Must be able to effectively collaborate with primary care teams and specialists.

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