The RN will work in the VPC department to support and provide clinical oversight, in conjunction with the Primary Care Medical Directors, and Director of Population Health, to the VPC care team. The RN will serve as an available resource for patients and clinicians, and act as a care guide to support patients through the continuum of care. He/she will carry out assigned nursing tasks and orders as delegated by the clinicians to support patient care.

Responsibilities:

• Assists all patients through the healthcare system by acting as a patient advocate and navigator.
• Participates in patient-centered team meetings and quality improvement initiatives. 
• Facilitates health and disease patient education.
• Supports patient self-management of disease and behavior modification interventions.
• Coordinates (in conjunction with other care team members) continuity of patient care with external healthcare organizations and facilities, including the process hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
• Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits. 
• Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
• Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Facilitates patient medication management based upon standing orders and protocols.
• Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to primary care.
• Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures. 
• Follows standard procedures and protocols related triage and escalation of care.
• Follows protocols and acts on standing orders per clinician guidance to assist with refills, ordering preventative/screening interventions, etc. within RN scope of practice.
• Collect and analyze biometric data to support various population health and patient care initiatives
• Provides support to medical assistants regarding clinical guidelines and protocols

Requirements:

• Bachelor of Science in Nursing (Current RN license in state of residency. Additional multi-state licensure may be required in other states which Doctor on Demand will facilitate.)
• Excellent verbal communication skills
• Proficient computer skills, including experience with google suite
• Must have experience working in an electronic health record system or have previous database experience 
• 2-5 years experience in a clinical setting, ideally with chronic disease management care

#LI-Remote

About Included Health

Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at includedhealth.com.

-----

Included Health is an Equal Opportunity Employer and considers applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics or any other basis forbidden under federal, state, or local law. Included Health considers all qualified applicants in accordance with the San Francisco Fair Chance Ordinance.