About Us A Specialty Path to Good Health Upperline Health is the nation’s largest provider group dedicated to lower extremity, wound and vascular care. Founded in 2017 with the ambitious goal of transforming specialty care, Upperline Health is a pioneer in bringing value-based care models into specialty care. Upperline delivers a more efficient path for patients to receive consistent and effective treatment for chronic illnesses. Triage is temporary. Treatment is transformative. Upperline Health providers coordinate patients’ care among a team of specialists – physicians, advanced practice providers, care navigators, pharmacists, dieticians, and social workers for integrated treatment that addresses patients’ immediate and long-term health needs. We put patients at the center of value-based care. About the Registered Nurse Role Upperline Health is seeking a weekday Registered Nurse to support a team of clinicians in delivering complex plans of care in accordance with the patient’s health status and overall goals and values. This individual will be based in one of our Upperline markets and will be responsible for providing care navigation and patient support as well as coordination of post-discharge care management services. This role supports high-risk and recently discharged patients to ensure safe transitions across care settings, prevent avoidable readmissions, close care gaps, and improve quality outcomes under value-based care contracts. This will include a range of clinical and administrative tasks such as directly providing telephonic support to patients, families and working collaboratively with the team of Nurse Practitioners and ancillary staff. Ideal candidates will have experience working with an older adult patient population and telehealth triage experience. Most importantly, candidates must demonstrate compassion for patient needs, have great attention to detail and thrive in a collaborative environment. What You'll Do:

• Telephonic care management with patients and their families, including triaging incoming calls and addressing and escalating urgent patient issues, as well as making proactive outgoing calls as requested by Upperline’s Providers.
• Provide chronic care management and transitional care management outreach, assessment and intervention to assess, identify and close clinical and non-clinical gaps in patient care.
• Appropriate triage and escalation of routine, urgent and emergent patient issues.
• Clinical care coordination with other providers and specialists, including:
  • Upperline clinic, telephonic, and home-based visit coordination
  • PCP or specialist office visit appointment coordination
  • Initiating clinical service orders on behalf of the patient
  • Initiating health plan authorization for Home Health, DME, Home Infusion and other critical services. Verifying the timely delivery of these services.
• Medication reconciliation and management to include the following, prescription updates and refill requests, identifying potential medication issues, answering patient questions on side effects and medication conflicts, and coordinating refills in coordination with Upperline Pharmacy team.
• Various clinical and administrative tasks.
• Potentially participation in weekly/monthly interdisciplinary team meetings and clinical huddles.
• Other related duties as deemed necessary by Upperline Health

• Candidates should be excited and energized by the prospect of working collaboratively as part of an innovative team
• Active Compact RN licensure required A plus if you are licensed in CA, CT, or MI
• Minimum of 3 years clinical experience required, preferably in a centralized care management team environment
• Prior healthcare experience serving chronically ill patients preferred
• Previous experience in ER, Critical Care or Home Health a plus
• Strong customer-service orientation
• Previous experience with Athena EMR a plus
• Must be able to help provide weekend and holiday coverage on a rotating basis
• Patient, compassionate and professional demeanor required
• Exceptional organizational skills and ability to multi-task
• Self-starter with an entrepreneurial spirit and demonstrated problem solving skills
• Strong writing, Word, Excel, and database management skills
• Extremely strong work ethic
• Experience working in a fast-growing, rapidly changing environment