Coordinating & Transitional Rn Case Manager | Hybrid | Asheboro, Nc

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 and Transitional RN Case Manager (CRN/ETOC RN) work closely with patients and the clinical care team members to support the ongoing and coordinated care of UpStream's patient population.In addition to the CRN/ETOC RN, the clinical care team also consists of a Clinical Pharmacist (CP), and a team of Health Concierges (HCs), who typically hold a Medical Assistant certification or a practical nurse license.
As an integral member of the care team , the CRN /ETOC RN primarily provides high quality care within the field and clinic setting to support the ongoing and coordinated care of UpStream's patient population . In collaboration with the clinical care team and Primary Care Provider, the CRN/ETOC RN offers complex care management support aimed at eliminating the burden of chronic diseases. This includes identifying abnormal clinical findings, resolving and preventing critical events, controlling conditions, decreasing avoidable hospital admissions (and readmissions), ensuring safe care transitions, and improving self-management skills.
The CRN/ETOC RN contributes 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.
This particular role will be supporting our practices in the Asheboro, NC area. Approximately 60% remote work, 40% field-based work.
What You'll Do -
In conjunction with the Primary Care Team and other members of the clinical care team, the following key services are performed by the CRN/ETOC RN

• Comprehensive nursing and social determinant of health assessment with required EMR documentation
• Disease management of high-risk chronic conditions.
• 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.
• Teamwork and Care Plan items:
  • Close collaboration with the clinical care team to build a Care Plan inclusive of findings from the therapeutic work-up and nursing assessment.
  • Fostering team care by gathering the patients baseline medical and psychosocial risks and creates individualized patient care/treatment plans to be carried out by nurses, pharmacists, health concierge, and/or partners with primary care and specialties.
  • Evaluation of effectiveness of care plan resulting in adjustments and edits to support achievement of personal patient goals.
  • Performs analysis of the effectiveness and appropriateness of patient care plan; and modifies care plan based on assessment and evaluation.
  • Delegation and clinical oversight of the HC staff providing clinical outreach, coordination of care, coordination of community resources, and care gap closure to the patient and family.
  • Plans, develops, assesses, and evaluates care provided to specific patient populations and engages team of HCs to divide workload among team where appropriate.
  • Develops and collects data; analyzes utilization of health care resources, including interpretation and application to case load decision making where appropriate.
• Outreach and health promotion services that are offered predominately via telephone but may require home visit with the patient as needed.
• 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.
• Ensures accurate medication reconciliation and supports ongoing adherence through patient-specific support. This is done in collaboration with CP on care team when appropriate.
• Facilitation and/or procuring timely access to appointments and services required by patient.
• Patient and family/caregiver education.
• Advocates the completion of living wills and advance care planning and where appropriate begin palliative care consults and/or hospice referrals.
• Communicates clear, complete, and accurate documentation in a health record to ensure that all those involved in a patient's care have access to information upon which to plan and evaluate their interventions.
• Leads post discharge activities including home-based post-discharge activities and participates in daily huddles with the clinical care team.
• Nursing and social determinant of health assessment focused on post discharge support.
• Exacerbation management and post discharge stabilization to prevent readmissions.
• Assesses root cause related to cause of hospital admission and provides feedback to clinical care teams.
• Recommends alternative levels of modalities of care and ensures compliance with federal, state and local requirements.

General Expectations for the CRN/ETOC RN -
The CRN/ETOC RN is an essential role within the Clinical Care team and has the following role expectations:

• Delegation to and clinical oversight of the Health Concierge (HC) staff related to clinical care aspects. Including but not limited to outreach assignments, coaching and feedback related to documentation and patient engagement.
• Hybrid support to the clinical care team which consist of:
  • Attendance in daily and weekly care team meetings.
  • Occasional onsite visit to the primary care office to meet with physicians or patients.
  • Home visits to patients with complex medical or social needs.
  • Telephonic outreaches to patients.
• During the transition of care period, the CRN/ETOC RN provides reactive support focusing on the needs triggered by an admission notice. The CRN/ETOC RN supports the clinical care team in the "transition" phase post discharge and ensures the patient is stable to be transitioned back to longitudinal care. During the TOC support period, the CRN/ETOC RN has the following role expectations:
  • Oversight of post discharge phase
  • Stabilization of clinical and non-clinical needs post discharge
  • Additional home visits during ETOC period
  • Attendance in daily discharge huddles

Experience and Skills You'll Need -

• Registered Nurse with bachelor's degree or equivalent
• At least 3 years of direct practice experience
• Active Registered Nurse License in the state providing services
• Experience in case management, critical care, emergency care or home health strongly preferred
• Previous experience as a RN Case Manager or in acute care management preferred
• Understanding of population health preferred
• Excellent patient service skills
• Ability to maintain 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 with various technology platforms and using multiple electronic medical records
• Adept at using Microsoft 365, including Word, Excel, Outlook and Teams

Location/working arrangements - Hybrid (Remote & Field-based)
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.