Role Description This is a 100% remote position; however, candidates must reside in Ohio. The Resource RN provides nursing support to members with low-acuity, short-term clinical needs. This role does not carry an assigned member panel; instead, the Resource RN works from a task-based queue to address targeted clinical needs. Responsibilities include: - Providing clinical education - Delivering focused interventions - Supporting care transitions following inpatient or emergency department visits - Conducting chart reviews and evaluating clinical data to identify members who may require higher levels of care management or short-term clinical intervention Key Responsibilities: - Outreach to members while admitted inpatient or after inpatient or emergency department discharge to conduct focused transitions of care assessments - Outreach to case managers for members that are admitted inpatient to assist with discharge planning as needed - Complete self-efficacy and condition-specific screeners including behavioral health tools like PHQ-9, GAD-7, AUDIT, or DAST-10, to identify members requiring behavioral health programming - Conduct in-person clinical exams if appropriate and collaborate with care team members to determine if a different intensity program placement is needed - Conduct comprehensive medication reconciliation and address contracted and company-prioritized quality gaps, ensuring proper chart documentation and appropriate ICD or CPT coding as evidence of gap closure - Triage referrals from the Population Health Partner for short term clinical interventions and chronic disease management - Meet members in various community settings such as homes, shelters, or hospitals, serving as an extender of care team providers and performing tasks like administering injections, monitoring vital signs, and in-home medication reconciliation - Review charts and data signals for potential transition to higher level of complex care management. Facilitate follow ups and hand offs to care team as needed - Utilize care facilitation, electronic health records, and scheduling platforms to collect data, document member interactions, organize information, track tasks, and communicate effectively with the team, members, and community resources Success Metrics: - Timely outreach to members and hospital case managers for transitions of care support - Completion of focused transitions of care assessments, ensuring accurate medication reconciliation and follow up visits are scheduled - Identification and timely escalation of members requiring higher-intensity programs or behavioral health interventions - Completion of assigned queue tasks within established timelines - Efficient management of multiple short-term clinical assignments without compromising quality - Effective communication and collaboration with care team members, Population Health Partners, and community providers Qualifications - Graduate of an accredited school of nursing (R.N.) - 3+ years of experience Requirements - Strong critical thinker with sound clinical judgment who makes complex decisions independently and knows when to collaborate - Identifies system barriers to care and develops creative, practical solutions - Demonstrates a growth mindset and openness to innovative approaches to improve outcomes - Strong written and verbal communicator across phone, text, virtual, and in-person settings - Comfortable using technology to engage members remotely - Applies Motivational Interviewing and Trauma-Informed Care principles to build trust - Effectively translates clinical information for non-clinical audiences and actively listens to understand and address needs Benefits - Health insurance - Life insurance - Retirement benefits - Participation in the company’s equity program - Paid time off, including vacation and sick leave