CINQCARE is a provider-led, community-based comprehensive health and care partner.

CINQCARE’s purpose is to every day improve the health and well-being of those who need us the most – with a deep commitment to Black and Brown populations – in their homes and communities. It requires the collaborative and cohesive effort of numerous individuals across all levels of the organization to deliver on this purpose. One community at a time, we are determined to help create a world where health and care isn’t a burden. Because we believe providing care is a privilege – one we are grateful to earn. That’s why CINQCARE has built a different way to care.

CINQCARE was born different. We were created to be on call to answer the call every day. We are driven to deliver health, care and well-being to those who need us the most and to relentlessly support our team members on the front lines. That’s our calling and if it’s yours we hope you’ll join us.

Overview

The RN Advocate reports to the Director of Care Coordination or designee, with accountability for providing strategy, judgment, organization, and evidenced-based analysis to influence decisions, and directly to meet Care at Home’s requirements. They should embody Care at Home’s core values, including, Trusted, Empathetic, Committed, Humble, Creative and Community-Minded. At Care at Home, we don’t have patients or customers – we have Family Members.

Care at Home model is designed for member engagement of the high-risk population with an emphasis on event-driven care management leveraging care pathways and evidenced based guidelines tailored to black and brown populations. Care Management includes assessing healthcare needs, identifying problems and opportunities for improvement, implementing patient Action Plans, managing the patient care transition process, assisting patients throughout care episodes, coordinating, and facilitating care for patients with complex, chronic medical and mental health conditions, providing disease education, and promoting evidence-based healthcare services. The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for patients/families struggling with chronic disease management. It is critical that care management be done in conjunction and always with the Caregiver, including their and the member’s signoff. Conducting Caregiver assessments are also part of the Care Management process.

About You

The RN Advocate should have the following qualifications:

· Education: Active IL Registered Nursing license.

· Experience: At least 5 years of relevant clinical experience. Ideal candidates will have 3+ years of relevant care management experience in the health plan, home health and or hospice.

· Entrepreneurial: Care at Home seeks to fix gaps that have persisted for generations in the delivery of care to Black and Brown populations. This position is accountable for ensuring Care at Home is positioned to innovatively deliver on its promise. The RN Advocate will possess the ability to work independently and initiate change within their responsibilities.

· Communication: Excellent verbal, written communication, and presentation skills; ability to clearly articulate and present concepts and models in an accessible manner.

· Relationships: Ability to build and effectively manage relationships with patients, the community business leaders, and external constituents.

· Culture: Good judgement, impeccable ethics, and a strong team player; desire to succeed and grow in a fast-paced, demanding, and entrepreneurial Company.

About the Job

Primary Responsibilities

The RN Advocate will have the following responsibilities:

· The individual in this position works as part of an interdisciplinary team to ensure high quality outcomes for Care at Home’s Family Members/families struggling with chronic disease management.

· Develops Alert-driven care pathway templates by condition with risk levels and member actions by event type.

· Uses Care Pathway templates by Chronic Condition with Alerts to develop Member Action Plans.

· Deploys Remote Patient Monitoring and Patient Self Reporting for High-Risk Chronic Conditions.

· Conducts in-home or tele-health assessments, when necessary.

· Responds real-time to Family Members alerts and is in active communication with the member and caregiver via text and phone. Monitors remote patient monitoring tools and notify interdisciplinary team when follow-up is required to address out of range results and or clinical outcomes.

· Provide care coordination for Care at Home’s Family Members including patient navigation, chronic disease management/education and interdisciplinary collaboration while complying with department policies and procedures and other contractual requirements.

· Work with patient and care team to conduct assessments that result in a Member Action Plan prioritized by the patient and care givers. Track Member Action Plan outcomes, interventions, and continue to reassess the patient's needs as appropriate. Establish appropriate timeframe for frequency of follow-up activities and provide closure and referral services as patients move through the care continuum.

· Engage patients in taking a proactive role for managing their health, medications, treatment and mental health needs, and follow-up appointments and refer patients to the appropriate community-based organizations or other programs.

· Follow evidence-based guidelines and contact standards to facilitate closure of gaps in care and encourage and use of in-network services and determine when in-home services are needed and ordered.

· Use the electronic medical record or Care Management platform to conduct care coordination activities and comply with associated policies and procedures including those for workflow and consistent documentation.

· Participate in team-based rounds to support and contribute to ongoing program design and development as lessons are learned from the field and process improvement work performed within the department.

· Reassess Member Action Plan Post Discharge.

· Demonstrates an ability to identify and shift priorities within work assignment to effectively manage patient care load.

· Collaborates daily with interdisciplinary team for assigned patients to discuss patient care planning and care facilitation.

· Perform other job-related duties as assigned.

General Duties

The RN Advocate will have the following duties:

· Leadership: The RN Advocate will lead in defining and executing strategies and solutions to create business value in the clinical practice, including working with their team to design, develop, and execute those strategies and solutions to deliver desired outcomes.

· Strategy: The RN Advocate will establish the business strategy and roadmap: (1) improve outcomes for Care at Home Family Members; (2) enhance the efficacy of other Care at Home business divisions; and (3) develop and deliver external market opportunities for Care at Home products and services. In establishing the business strategy, the RN Advocate will define and innovate sustainable revenue models to drive profitability of the Company.

· Collaboration: The RN Advocate will ensure that our clinical capabilities form a cohesive offering, including by working closely with other business divisions to learn their needs, internalize their knowledge, and define solutions to achieve the business objectives of Care at Home.

· Knowledge: The RN Advocate will provide subject matter expertise in the clinical solutions, including determining and recommended approaches for highest quality medical care, including assessment and event-based care management

· Culture: The RN Advocate is accountable for creating a productive, collaborative, safe and inclusive work environment for the clinical team and as part of the larger Company.

CINQCARE provides all employees working an average of 30+ hours/week with the option to enroll in healthcare benefits. The cost of healthcare is shared between the company and the employee.

The working environment and physical requirements of the job include:

This position requires both in-home and office-based work. The job requires frequent travel for home visits and travel to physician offices, hospitals, sub-acute facilities, community partners and non-home-based market offices in all types of weather conditions. In-office work is performed indoors in a traditional office setting with conditioned air, artificial light, and an open workspace.

In this position you will need an ability to travel frequently by car and/or public transportation, the ability to communicate with customers, vendors, management, and other co-workers in person and over devices, sometimes with people who are agitated. Regular use of the telephone and e-mail for communication is essential. Sitting for extended periods is common. Must be able to receive ordinary information and to prepare or inspect documents. Lifting of up to 30 lbs. occasionally may be required. Good manual dexterity for the use of common office equipment such as computer terminals, calculator, copiers, and FAX machines. Good reasoning ability is important. Able to understand and utilize management reports, memos, and other documents to conduct business.