Transition & Housing RN (Western North Carolina)

LOCATION : Remote - must live in or near Caldwell, McDowell, Mitchell, Watauga, or Yancey County, North Carolina. The person in this role is required to reside in North Carolina or within 40 miles of the NC border. This is a home-based position that requires community travel .

GENERAL STATEMENT OF JOB

Performs nursing assessment and support for adult members that are medically fragile or have significant chronic health conditions, have a mental health, substance use or co-occurring disorder who are transitioning out of Adult Care Homes (ACH) into the community. Individuals served may also have a co-occurring intellectual or developmental disability. This position will work collaboratively with other Vaya staff, behavioral health providers, Primary Care Physicians, specialty care providers and other community partners and stakeholders to support members in their home communities. Work is performed under the supervision of the Transition and Housing Nurse Supervisor.

The role can involve a range of scenarios which require a wide array of potential responses including micro and macro level interventions. These may include, but are not limited to assessment, care monitoring, and care planning, patient and family education, medication reconciliation, researching, linking, reviewing documentation, phone communication, attendance at treatment team meetings, and consultation. The nurse on this team will have regular visits with patients in ACHs and with patients living in the community. The nurse may, assess health literacy, provide patient and family education, facilitate clinical rounds, partner with ACTT RN, EMS, or other medical providers on routine patient home visits, be a consultative resource for other Vaya team members.

ESSENTIAL JOB FUNCTIONS

Assessment, Coordination, Care Plan Development and Safety Oversight :

• Proactively ensures individuals identified as transitioning out of ACHs and / or Special Needs enrollee receive RN Assessment and are linked to a Behavioral Health Clinical Home and a Medical Home
• Coordinate community service planning and attend care team meetings.
• Ensure service needs are addressed and coordinate the collection, entry, maintenance, analysis and reporting of data associated with psychiatric and medical treatment.
• Assist in development of participant care plan
• Appropriately escalates high risk scenarios to appropriate leadership. High risk can involve Health & Safety of an individuals served, staff or organizational risk
• Provides Medication Reconciliation
• Uses data, assessment, chart review and supervision to measure results of interventions and treatment, including reduction in high-risk events
• Ensures that services for the individual are coordinated across the Vaya Health system and with other healthcare and social determinant systems
• Understand the role of and collaborate with Transition and Housing teams, Acute Response team, Hospital Emergency Department, or Inpatient Discharge planning teams, participate in developing transition plans, educating staff and members regarding network services and supports with consideration of medical necessity, funding eligibility and appropriateness of recommendations relative to person centered, recovery principles and known best / appropriate practice.

Collaboration :

Documentation :

Staff Education :

KNOWLEDGE, SKILLS, & ABILITIES

EDUCATION & EXPERIENCE REQUIREMENTS

Associate Degree in Nursing with licensure as a Registered Nurse in North Carolina and two (2) years of general nursing experience is required. Bachelor's degree in Nursing preferred.

Licensure / Certification Required :

Must be licensed as a registered nurse in North Carolina.

PHYSICAL REQUIREMENTS

RESIDENCY REQUIREMENT : The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY : Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION : Open Until Filled

APPLY : Vaya Health accepts online applications in our Career Center, please visit https : / / www.vayahealth.com / about / careers / .

Vaya Health is an equal opportunity employer.