Care Management Nurse Educator | Field-Based
At UpStream, we are dedicated to promoting good health and empowering individuals to lead independent lives. As a trusted partner to primary care physicians, we offer effective and sustainable care options, focusing on seniors and those with chronic conditions. Our comprehensive solution allows physicians to prioritize patient care while our value-based care model ensures effective condition management.
We prioritize affordability and accessibility, collaborating with healthcare practices and clinics to reduce costs and enhance system efficiency. Through personalized care plans and innovative solutions, we strive to improve health outcomes and enable patients to live fulfilling, independent lives.
How you’ll help
UpStream employs the Coordinating Registered Nurse III (CRN III) also known as the Nurse Team Lead, to embody, empower, and engage the UpStream nurses in highest capacity to drive improved patient outcomes.
The Nurse Team Lead functions as the local nursing subject matter expert, preceptor and leader for the nursing team. As a nursing SME, the Nurse Team Lead is an expert in Care Management and the UpStream model of Care. This role supports and offers precepting services to the new UpStream Nurses and existing nurses. The Nurse Team Lead continues to work closely with staff, Primary Care Team, and other Interdisciplinary Clinical Team members to support the ongoing and coordinated care of UpStream’s patient population. In collaboration with UpStream’s Practice Operations team, the Nurse Team Lead offers the nursing team feedback, guidance and coaching for the nursing practice at UpStream. The Nurse Team Lead works closely with the CRN II to understand performance and coach and develop nurses.
The Nurse Team Lead is an integral member of the interdisciplinary care team and contributes to UpStream’s patient-centric, emotionally present, and relationship-based culture. We seek individuals interested in positively contributing to this culture and growth.
This position requires maintenance of confidentiality, discretion, critical-thinking, flexibility, and exceptional patient service. This position is primarily based in the local market observing nursing visits in patient homes and primary care offices.
What you’ll do
General Responsibilities of the Nurse Team Lead (CRN III)
- Works in conjunction with the Primary Care team, UpStream’s Director of Clinical Operations, interdisciplinary care team, and others to plan and implement patient’s medical and non-medical care.
- Together with the patient, identifies medical and psychosocial risks and collaborates with interdisciplinary care team on individualized patient care/treatment plans to be carried out by transition care specialists, pharmacists, clinical medical assistants, care coordinators, and/or partners with primary care and specialties.
- Assesses patient/family abilities to self-engage and collaborates on individualized patient/family education plan focused on development of self-management skills based on standard care protocols.
- Advises/educates patient, family/caregiver on importance of medication adherence and collaborates toward the removal of adherence barriers.
- Advocates for the completion of advanced directives or living wills, provides support for advance care planning and palliative care referrals where appropriate.
- Assists with data collection used to analyze utilization of health care resources, including interpretation and application to case load decision making where appropriate.
- Performs analysis of the effectiveness and appropriateness of patient care plan based on assessment and evaluation.
- Communicates clear, complete, and accurate documentation in the health record to ensure that all those involved in a client’s care have access to information upon which to plan and evaluate interventions.
- Communicates patient’s progress with prescribed care with all those involved in a client’s care upon which to plan and evaluate their interventions.
- Understands and reinforces UpStream Nursing Care pathways and workflows related to the patient journey.
- Full understanding of tasks performed by each team member – not competent in each task, but able to detect when a team member may need support or mentoring re: the completion of a task.
- Understands and reinforces the clinical operations process and subsequent services provided by UpStream to fully support Nursing team.
- Responsible for providing local support and guidance for the UpStream clinical staff in accordance with policies, care pathways and workflows.
- In alignment with the Nursing care pathways and workflows, Identify and direct clinical tasks to ensure the team is optimally working together to meet patient needs.
- Facilitate the flow and understanding of company information, changes, and updates.
- Identify and document opportunities to improve the quality of processes and clinical workflow to maximize patient and business outcomes.
- These findings will be gathered in formal nursing development tool and shared with UpStream Nursing leaders.
Supporting the Nursing Role within the UpStream Team through Education
- In partnership with the UpStream Training and Development team, Nurse Team Lead offers assistance and support with educational activities for the CRN role.
- Education content related to Nursing scope.
- Educational content related to Healthcare and Population Health services offered in Core Curriculum.
- Promoting educational opportunities of each Nurse, working to ensure that each team member is developing towards their full potential.
- Support for Case Reviews and collaborative care by the nursing role.
- Support new nurses by offering nurse Preceptor services. This includes the following:
- Coordinating and scheduling the nurse hire for joining new and follow up patient visits.
- Allowing the new nurse to see the nursing role in the home from start to finish including all documentation.
- Reviews and facilitates access to learn all onboarding checklist requirements.
- Provides feedback to improve the RN’s assessment and management skills.
- Provides comprehensive learning experiences in varying environments to include telephonic, clinic and home-based areas.
- Promptly communicates issues of concern or unsafe practice to local Nursing leadership.
- Ensures participation in TEAM and Nursing Leadership meetings.
- Identifies opportunities for training and development for the preceptee.
Locally Supporting the Nursing Role within the UpStream Team through Oversight
- In partnership with the Senior CRN (CRN II), the Nurse Team Lead develops and audits nursing staff.
- Communicating and reinforcing nursing performance and role expectations after in person and virtual audits are completed.
- Sharing nursing opportunities and areas for improvement along with acknowledgement of successful performance
- Ensure employees receive regular performance conversations based on team and individual performance expectations – the role will lead and schedule these performance conversations.
- Understand strengths & opportunities of each Nurse, working to ensure that each team member is developing towards their full potential.
- Monitoring individual nurse performance data dashboards to assess gaps in performance and patient care.
- Focus on engaging Nurses in their role including but not limited to addressing/clarifying employee expectations, answering daily process and team collaboration questions, recognizing employees for quality patient and team engagement, communicating changes and updates to employees.
- Handle Nurse relations issues and elevates concerns when necessary.
- Engage team members by creating a patient-centric and positive team environment.
- Elevate the CRN Critical Thinking skills.
- Support and collaborate with UpStream Directors and Managers to ensure Nursing services are operating within UpStream Standards.
- Provide feedback and recommendations for development of UpStream nurses in partnership with UpStream Directors.
- Work collaboratively from a nursing perspective with other UpStream Leaders to support nursing enhancements, oversight, and programs.
- Participate in the hiring and termination of clinical team members.
Locally enhancing the Nursing Foundation: Resources and Partners
- Manage local connections with provider groups and community resources.
- This includes but is not limited to:
- Coordinating and scheduling the local meet and greet sessions for local Nursing team including Clinical and non-Clinical partners.
- Supporting the creation and maintenance of the repository of resources for the local nursing team
- Working to outreach and engage new community partners and resources.
- Support for Nursing leadership locally in Provider meet-n-greets.
- Including introduction to UpStream Nursing services, Overview of key programs and services offered by UpStream Nursing staff.
Experience and skills you’ll need
- Registered Nurse with Bachelor’s Degree or Equivalent with 5-8 years of practice experience
- Experience as a Nursing Leader
- Experience with Care Management
- Care Management Certification Preferred
- Understanding of population health management preferred
- Excellent patient service skills
- Ability to maintain a positive work environment and personally connect with patients, caregivers, and fellow team members
- Must be able to work independently and interdependently within a team
- Strong analytical and critical thinking skills
- Excellent written and verbal communication skills.
- Strong attention to detail
- Must be self-motivated and willing to adapt to changing processes.
- A desire to be part of something bigger than oneself.
- Competency in electronic medical records, desirable
- Comfortable using Microsoft 365, Word, Excel, and Outlook
Location/working arrangements – Field Based
At UpStream we offer a range of benefits to ensure our employees are taken care of. Our health insurance plans through United Health Care include FSA and HSA options, and we also offer dental, vision, life, and accident coverage through Guardian. We immediately match contributions to our 401k plan, which includes both Roth and Traditional options. In addition, we provide financial perks and rewards through BenefitHub, and free access to EAP services through WorkLifeMatters. Our employees also enjoy generous PTO and paid holidays.
We value diversity and promote equal opportunities for all. As an equal opportunity employer, we do not discriminate against applicants based on their 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. All qualified candidates are encouraged to apply.