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Position Summary:

The Virtual Care Nurse supports operations of the RPM program at Stony Brook Medicine. Provides virtual survelliance of all patients on RPM service; diverse patient populations. Monitors patient?s biometrics, survey and engagement data, trends from multuiple devices, and escalates to overseeing medical provider for concerning trends when appropriate. Deals successfully with complex clinical problems. Conducts quick assessments of patients through the RPM technology and handles urgent or emergent situations appropriately. Works under general supervision and is a part of an interdisciplinary Care Management team. Responsible for end-to-end comprehensive service delivery, overall care planning and performance metrics for assigned RPM caseload.

General Functions:

• Monitors patient?s biometrics, survey and engagement data and escalates/informs overseeing medical provider of concerning trends when appropriate; Use the nursing process to assess patient problems and concerns; critically analyze and integrate subjective and objective data.
• Consults with Physician and other healthcare providers to resolve immediate health concerns for patient enrolled in RPM service.
• Provide continuous accountability to assess, plan, implement and evaluate Clincial Care related to RPM services and adherence to Care Plans.
• Involves patients and families in shared decision making; advocate for paitent and family; accessing relevant health services
• Coordinates nursing care and follow up services for patients and family members in specific healthcare locations by telephonic, electronic, in person or by email
• Demonstrates an understanding of care management, complex disease management, transitions of care, post-acute care landscape/options, and community management standards. Maintain familiarity with community resources and agencies for assigned locality and update resources as necessary
• Demonstrates an understanding of current climate of economics and funding resources for care delivery/care management. Utilizes resources efficiently and effectively.
• Demonstrates an understanding of managed care trends, payer regulations, reimbursement, and the effect of utilization on the different methods of reimbursement.
• Works as part of an interdisciplinary team; facilitates communication and coordination between members of the healthcare team in the care planning process. Assists in eliminating boundaries to achieve integrated, efficient, and quality service.
• Participates in interdisciplinary ?team rounds? to address utilization/resources and progression of care issues. Assists in developing and implementing an improvement plan to address issues.
• Adheres to communicated care management productivity metrics, and maintenance of caseload as per policy. Adheres to quality standards, including adherence to model of care/standard operating procedures as well as comprehensive documentation, actionable care plans, and appropriate cases closed in a timely fashion.
• Develops strong working relationships with internal and external customers to provide exemplary service and achieve goals.
• Proficiency in various word processing, spreadsheet, graphics, and database programs, including Microsoft Word, Excel, PowerPoint, Outlook, etc.
• Demonstrates the ability to evaluate utilization/resource/clinical care management data to identify trends, develop action plans, and program modification for improved outcomes.
• Participates in special projects or other duties as assigned.