TotalMed
Responsibilities:
Complete at least 10 NF member assessments per week
Support rebalancing initiative by assessing, screening, and transitioning NH members to community care
Visit NF members in person at least twice weekly
Conduct in-person or telephonic home assessments prior to discharge to ensure environmental supports (e.g., ramps, DME) are in place
Perform Significant Change Visits within 5 days of transition, establish Plan of Care, and document interventions
Collaborate with facilities, Social Services, and Case Managers to coordinate safe discharges
Provide interventions for high-risk community members to prevent lapses in care
Contact facility Business Offices weekly to track census and coordinate discharges
Participate in at least two community relations events annually
Build and maintain strong community/provider relationships to enhance member satisfaction and retention
Required Skills & Education:
RN license in Florida – active, unrestricted, and in good standing
Associate Degree in Nursing (required), BSN preferred
2+ years of clinical experience (hospital, home health, ambulatory care, or similar)
Bilingual (Spanish/English) required
Strong computer literacy and ability to manage multiple systems
Effective verbal and written communication skills
Travel up to 75% to conduct member visits and transitions