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(Archived) RN - Chronic Care (Field)

Last Updated: 2/20/19

Job Description

Position Summary

The focus of the Matrix Chronic Care team is to stabilize a member’s health, identify and close gaps in care, coordinate, collaborate and provide medical/behavioral/social care support to the member in between their visits to their primary care provider that result in an enhancement to their health status and a reduction in overall health costs. The Care Direct RN will also focus efforts on engaging the member with a goal of ensuring they become and/or remain motivated to take an active role in maintaining a stable healthcare status.

As an essential member of the Matrix Care Direct (CD) Team, the CD Registered Nurse (RN) will focus on assessing, coaching and educating the Adult health plan member with progressive, multiple chronic illness(s) with recent healthcare utilization on how to stabilize their health and transition effectively to their pre-hospital health state. The CD RN will be responsible for a caseload of members and will provide short term OR ongoing/longitudinal care in collaboration with the Care Direct Care Team until the member terminates /successfully graduates from the program or health plan. The CD RN performs an initial assessment of the member, formulates an individualized care plan(ICP) based on patient goals of care and member needs and coordinates care with CD Care Team to determine appropriate interventions necessary for the member to meet critical goals of care. The CD RN must be able to identify changes in members’ condition, provide interventions (with in scope of practice) and notify CD Care Team when more advanced measures are needed. The CD RN will coordinate all medical/behavioral and social resources needed to stabilize the member and assist them to meet goals. The CD RN will work collaboratively with the member, other members of the CD Care Team and the member’s PCP/Specialist to ensure alignment on goals, interventions and progress on health status.
Educational Requirements:

• Current unrestricted Licensure to practice as a Registered Nurse in the state(s) to which assigned
• Maintains nursing license in good standing.

Required Skills and Abilities:

• Has experience in home environment providing Chronic Disease care for the Adult population
• Strong customer service skills and is dedicated to meeting the expectations and requirements of both external and internal customers, acts with customers in mind; establishes and maintains effective relationships with customers and gains their trust and respect
• Works collaboratively with other members of the Care Direct Care Team
• Utilizes behavioral interviewing techniques when interviewing members/patients, care stakeholders to determine health care interventions that have the best chance of success
• Demonstrates the ability to meet each patient’s individual needs
• Demonstrates the ability to develop an Individualized Care Plan in collaboration with the patient/patient’s Care Giver/Primary Care Provider.
• Effectively communicates both verbally and in writing to members to care stakeholders and other healthcare professionals
• Ensures patient autonomy and self-determination and uses behavioral interviewing techniques when determining patient’s readiness to change health status.
• Effectively copes with change and uncertainty, responds and “shift gears” comfortable
• Demonstrates functional and technical knowledge and skills to competently perform all aspects of the job
• Effectively manages time and is able to prioritize work
• Uses logical methods to solve problems with effective solutions; is proficient at honest analysis, looks beyond the obvious for solutions
• Is action oriented and sees challenges as opportunities
• Practices attentive and active listening; has the patience to hear people out; can accurately restate the opinions of others even when he/she disagrees
• Consistently adheres to a core set of values and beliefs; acts in line with those values
• Has strong computer skills for case management documentation and follow up; must be able to use MS Word, Excel or a company provided application(s)
• Effective written communication skills including but not limited to writing reports and correspondence
• Effective verbal communication skills including but not limited to speaking effectively to members, providers, families and staff
• Demonstrates ability to meet deadlines
• Demonstrates successful experience working in an environment of change
• Completes all required documentation within establish protocols
• Must have a valid state driver’s license
• Must have proof of adequate automobile insurance coverage for the state of residence

• Minimum of 3 years’ experience as Registered Nurse evaluating and managing Adult/geriatric Patients with chronic medical conditions
• Current RN licensure in state of residence and state where caring for members if they are different
• Must be able to visit members in their private residence, skilled nursing facility and/or a hospital setting
• Must have experience evaluating and developing patient care and treatment using the Nursing Process (ADPIE)
• Must have ability to evaluate patient preferences in a positive manner
• Must have experience working with the Microsoft Office Suite (Outlook, Word, Excel) and Electronic medical records
• Experience in working in fast paced, growth oriented environment

Supervisory Responsibility: No supervisory responsibilities, may act as a field trainer in some positions with this title
Travel Requirements: Local Travel only

Work Conditions:
• Must be able to drive a car
• Must be insurable
• Must have a valid driver’s license
• Must be able to travel by public transportation and airplanes
• Requires prolonged sitting
• Requires bending, stooping, twisting, kneeling, crouching, crawling and/or stretching from seated or standing positions
• Requires eye-hand coordination and manual dexterity sufficient to operate medical equipment, keyboard, telephone, copier, calculator and other office equipment

Matrix Medical Network is Proud to be an Equal Opportunity Employer

Company Details

Matrix Medical Network

Scottsdale, Arizona, United States

Matrix Medical Network engages with members wherever they are in are in their journey to health improvement. Our national network of community-based clinicians deliver in-home services for members while our fleet of mobile health clinics provides community-based care with advance diagnostic capabilities. These options, and our advanced engagement approach, helps plans manage risks, close care gaps...