Registered Nurse needed for a virtual clinician role with an outpatient primary care practice in Northern Virginia!

Job description

AFM Virtual Clinician (VC) Roles/Responsibilities

RN+

The following duties may be required, but not all duties will be performed on every work day:

Annual Wellness Visits: performing the virtual portions, including the HRA (health risk assessment).
CCM (chronic care management) or APCM (advanced primary care management) roles/responsibilities.
RPM (remote patient monitoring) oversight as stated below.

Chart Preparation
Perform on all patients with an appointment within 1 month of the current date.
If there are no patients fitting criterion #1, then go back at least 3-6 months, and look at the first 1-3 problems in the assessment/plan section (focusing on patients who have providers no longer with AFM first).
Schedule an in-office follow-up visit for that reason(s) within 1 month of this review, if the patient is not already scheduled for an in-office visit. Schedule the patient for the appropriate patient visit type.

Nurse Line
Ability to field incoming patient calls (that have previously been filtered by Front Office Staff as appropriate) that are within the RN’s scope of practice.
Ability to refer patients appropriately as an outcome of these calls. For example, scheduling a patient with known hypertension for a follow-up telehealth visit after discovering they have a blood pressure reading of 150/100 with no other presenting signs/symptoms.
Ability to triage stated incoming patient calls into red-yellow-green priority, and determine appropriate next steps as such.

RPM Oversight
Regarding this care program, reviewing the appropriate patient dashboards daily, and triaging patients according to the red-yellow-green methodology. For example, a patient with a blood pressure of 150/100 can be scheduled for an In-Home Program paramedic visit, with immediate care making sure that the patient is not having red-level signs/symptoms.

Care Program Patient Outreach
Regarding AFM’s care programs, having a thorough understanding of the specific program. And, if the patient is eligible for the program, being able to explain the program to them clinically, and obtaining consent, if applicable. Once the patient is enrolled in the focused-upon program, then performing chart prep to ensure that there are no other gaps that need to be filled in the patient’s care.

Schedule Double-Check
This applies to the preceding day’s schedule. For example, if today is Tuesday, then reviewing Monday’s schedule.
Ensure that the patient is scheduled for a follow-up visit. If not, then determine the appropriate time frame for the follow-up, and forward chart to Virtual Scheduling (VS) team.
Ensure that the patient has no pending care gaps/quality measure deficiencies. If they do, then address them appropriately.
Ensure that the patient has been referred to all the appropriate care programs:
BHI/CoCM: for any patient that scored a 5+ on their PHQ/GAD assessment.
CCM: for any patient with 2+ chronic conditions.
RPM: for any patient with cardiovascular conditions such as a history of heart attack (aka, myocardial infarction), hypertension, and/or a stroke, for example. Also, for any patient with diabetes.
IHP: for any patient needing follow-up, e.g., a patient with elevated blood pressure in-office.
Cardiovascular program: for any patient with diabetes and/or cardiovascular conditions.
If the patient was referred to any care programs, then call patient to explain the program to them, and obtain consent. If patient agrees to program and has given consent, then forward chart to VS team for scheduling.

• 2-3 month need, with possibility to ramp-up to a permanent role
• Involvement with innovative care programs such as behavioral health implementation (BHI), collaborative care model (CoCM), and an In-Home Program (IHP)
• Work in tandem with another RN to assure job requirement is within practice scope as well as not too high in patient volume