Integrated Care Team RN

Accompany Health is on a mission to give low-income patients with complex needs the dignified, high-quality care they deserve but rarely receive. A primary, behavioral, and social care provider, Accompany Health walks alongside patients for their entire care journey, offering at-home and virtual care, as well as 24/7 support. Partnering with innovative payors, Accompany Health is powered by remarkable care teams, elegant technology, and a commitment to evidence-based practice. 

We build long-term relationships with our patients so they know, without question, that our team is here for them day or night, year after year. We focus on the health outcomes most important to our patients to make it clear that they lead the way.

To achieve our mission, we collaborate with community-based organizations, local providers, and health plans. Led by our empathetic care teams, guided by proven care models, and powered by our own technology, we deliver a level of service that our communities rightfully deserve but rarely receive. 

While our headquarters is in Bethesda, MD, our teams are distributed across the country.  If you’re eager to make a tangible difference in people’s lives, to help correct long-standing disparities in health care, join us. 

About the role:

Integrated Care Team Field RNs are a key part of our Integrated Care Teams, which also include Physicians, Advanced Practice Clinicians, Community Health Workers, Patient Experience Navigators, RNs, Social Workers, Behavioral Health Clinicians, Psychiatrists, and Pharmacists. Together this team is responsible for providing and coordinating holistic, patient-centered care for an intimate panel of patients with complex medical, behavioral health, and social needs. 

As an Integrated Care Team Field RN, you will provide patient support both virtually via video, telephone, or text, along with in the home and community visits. You will drive and quarterback pathways for chronic disease management (e.g. diabetes, CHF, COPD, CKD/ESRD) for a panel of patients to help empower patient and caregiver self-management. As a field RN you will be a patient advocate, ensuring the most vulnerable patients are supported, attended to, and enabled to live their best possible lives. As part of the Integrated Care Nursing Team you will provide support to our triage and transition of care nursing teams facilitating ongoing patient care with compassion and empathy while connecting them with appropriate care and resources that can keep them safely at home and out of the hospital when possible.

• Driving pathways for chronic disease management (e.g. CHF, COPD, CKD/ESRD, and diabetes) for a panel of patients, including performing clinical assessments, providing patient education and coaching, ensuring closure of quality gaps, connecting and navigating to appropriate services, and supporting remote monitoring. 
• Ensuring appropriate creation of care plans for patients qualifying for pathways and quarterback appropriate coordination, patient coaching,  and follow through on the plan.
• Leading case conferences for your patient panel and ensuring appropriate documentation on changes to care plans and progress.
• Providing virtual, telephonic, and in-home or community care for patients with poorly controlled chronic or acute illnesses. 
• Performing nursing interventions such as patient clinical assessments, administering vaccines and medications under the supervision of a provider or MD, performing wound care, and facilitating ongoing chronic disease management and patient education. 
• Establishing and fostering trusting relationships with your patients and ensuring that care is appropriately aligned with their goals and values. 
• Supporting nursing teammates in telephonic triage and transition of care through ongoing team collaboration and assistance as needed.
• Participating in multi-disciplinary case conferences and clinical rounds to ensure holistic and appropriate care for patients.
• Collaborating with external providers and community-based organizations to advocate for patient care aligned with their goals.
• Providing feedback on program design and workflows to ensure we are providing the best patient care possible.
• Modeling excellent communication, documentation, efficiency, and critical thinking skills to the interdisciplinary team.
• Roles and responsibilities may evolve as our care model develops. 

• Passionate about caring for complex, historically underserved patients with co-occurring chronic and behavioral health conditions in an integrated, multi-disciplinary model anchored in home-based and tech-enabled virtual care.
• Committed to providing the highest quality, outstanding clinical care to all patients, regardless of their needs.
• Consistently go the extra mile to ensure that our patients have the best healthcare experience possible.
• Excited to be a part of and contribute to the development of a rapidly evolving, innovative care model.
• Enjoys continuously learning and adapting workflows to improve patient care.
• Excellent communicator able to coach and mentor clinical and non-clinical members of multidisciplinary teams on excellent patient care. 

• Required
• Active, unrestricted Registered Nurse license in the state in which you are applying
• 3+ years of experience providing clinical services to Adult and/or Geriatric individuals with co-occurring chronic medical and behavioral health conditions, preferably in an ambulatory setting
• Possess exceptional critical thinking, coordination, and clinical assessment skills
• Experience in the creation and coordination of holistic care plans for common chronic medical conditions such as diabetes, hypertension, CHF, COPD/asthma, and CKD/ESRD
• Demonstrated ability to help a patient adapt new habits, change behaviors, and motivate towards achieving health goals
• Experience in and passion for providing health education for patients regarding chronic disease self-management in order to empower themselves and their caregivers in their health goals
• Experience and comfort working within an interdisciplinary care team, and specifically working alongside community health workers and care coordination team members
• Familiarity and willingness to travel within your community (home-based member visits) and its healthcare systems (hospitals and rehab centers)
• Comfort with electronic medical record documentation and excited about how technology can support your work and drive ongoing improvement towards new and better care
• Prior experience caring for patients in the home and/or community setting
• Valid unrestricted driver's license and access to an insured vehicle for daily use

• Preferred 
• Experience in adult internal medicine, family medicine, geriatrics, palliative care, and home-based care
• Demonstrated proficiency, prior experience, and/or willingness to train in clinical nursing skills such as wound assessment and care, blood drawing (venipuncture & phlebotomy)
• Experience in transitions of care management for patients being discharged from hospitals, skilled nursing facilities, and behavioral health facilities, including performing detailed medication reconciliation, patient education, and connection/navigation to appropriate services
• Experience in behavioral health settings and/or caring for patients with serious mental illness and/or substance use disorder
• Experience in trauma-informed care and practices
• Experience as an active participant in continuous quality improvement projects

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For Patient Facing Roles

To keep our patients, communities and each other safe, you'll be required to comply with Accompany Health’s medical clearance requirements, including completing a TB screen and providing proof of immunity or vaccination for certain conditions. You will also be required to be vaccinated and up-to-date on your COVID-19 vaccinations, including boosters. This is a condition of employment, and we make exceptions as required by law. Accommodation for religious and medical beliefs will be provided on a case by case basis.

For Non-Patient Facing Roles

To keep our patients, communities and each other safe, you'll be required to comply with Accompany Health’s medical clearance requirements, including receiving the COVID-19 vaccine. This is a condition of employment, and we make exceptions as required by law. Accommodation for religious and medical beliefs will be provided on a case by case basis.

We embrace diversity and believe it creates a healthier atmosphere:  Accompany Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.