Welcome to Pathways Health Partners, the Accountable Care Organization (ACO) that's leading the charge in helping independent providers transition to Value-Based Care.
What We Do:
Medicare REACH ACO: We're at the forefront of Medicare innovation.
Medicare Advantage MSO: Providing top-notch services to our Medicare Advantage patients.
Commercial MSO: Managing care for approximately 16,000 patients across North-West/Central Florida.
Where We Operate: From The Villages to St. Petersburg, and across to Mount Dora, we've got you covered!
Our Services:
Hospital Medicine Group: Delivering exceptional care in hospitals.
Affiliated Medical Practices: Managing several top-tier medical practices.
Insurance Agency: Offering comprehensive insurance solutions.
Join us on our journey to better health and value-based care!
Job Summary:
The GUIDE RN Coordinator in essence oversees the implementation and follow-up of GUIDE participants. The role focuses on improving caregiver support, patient/caregiver education on Dementia, keeping patients home as long and safe as possible.
Role and Responsibilities:
• Contracts for Respite Partners in coverage areas (In Home respite, Day stay programs, and 24-hour overnight facilities).
• Contracts for Practitioners for care plan oversite.
• Receive referrals and consents.
• Complete the initial assessment for GUIDE program and ready all documents for CMS Submissions (consent, initial assessment with FAST-ZARIT-PROMIS questionnaires, and Dr. note/H&P).
• Complete the comprehensive assessment as in-home visit F2F (face to face)
• Document and create care-plan in electronic health records (EHR).
• Provides resource packets to patients and caregivers.
• Complete monthly check-ins as program outlines.
1. Education: Registered Nurse
2. Experience: Minimum of 3 years of experience as RN, minimum 2 years in care coordination, or a related role within a healthcare setting.
3. Certification/Licensure: Valid Florida Driver License (unencumbered and no points), Florida Registered Nurse
4. Training and Knowledge Required at Time of Hire: Excellent computer skills with experience in Outlook, MS Office Suite, EMRs; positive and effective communication skills; Good typing skills.