Advanced Practice Nurse

1 day ago


Chicago, Illinois, United States Oak Street Health Full time
About the Role

Oak Street Health is seeking a highly skilled Advanced Practice Nurse to join our team as a Transitional Care Nurse Practitioner. As a key member of our care team, you will be responsible for delivering high-quality, patient-centered care to our most vulnerable patients in the comfort of their own homes.

Key Responsibilities
  • Provide post-discharge support to patients in their homes, ensuring a smooth transition from hospital to home care.
  • Develop and implement individualized care plans, working closely with patients, families, and healthcare providers to achieve optimal health outcomes.
  • Optimize and monitor patients' clinical status, identifying and addressing gaps in care, and reconciling medications to prevent adverse events.
  • Collaborate with Transitional Care Managers, home health agencies, social workers, hospitals, and specialists to ensure comprehensive care coordination.
  • Structure and prioritize patient scheduling based on clinical complexity, ensuring timely and effective care delivery.
  • Recognize, diagnose, and manage acute and chronic medical conditions to prevent destabilization and readmissions.
  • Provide after-hours and weekend call support, shared with other in-state providers, to ensure seamless care continuity.
  • Facilitate and conduct goals of care and advance care planning discussions with patients and families, respecting their values and preferences.
  • Assess and evaluate family/caregiver needs and limitations, providing education and support to ensure optimal patient care.
  • Teach patients, caregivers, and others about their health conditions, empowering them to take an active role in their care.
  • Accurately and timely document patient encounters in Oak Street's electronic medical record, ensuring compliance with regulatory requirements.
  • Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting, to maintain a culture of safety and quality.
Requirements
  • Active, non-probationary state medical license, including US work authorization, if applicable.
  • 1+ years APN experience, preferably with a Medicare population.
  • Experience in home-based care (as RN or APP) preferred.
  • Flexibility to travel throughout the service area.
  • Electronic Medical Record experience.
  • Computer skills: Ability to quickly navigate and use multiple computer programs.
  • Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required.
About Oak Street Health

Oak Street Health is a mission-driven organization dedicated to rebuilding healthcare as it should be. We provide personalized primary care for older adults on Medicare, with a focus on quality over volume. Our innovative care model is centered in our patients' communities, and we're committed to delivering exceptional care that improves health outcomes and enhances the patient experience.

We're an organization on the move, with over 150 locations and an ambitious growth trajectory. We're attracting and cultivating team members who embody our Oaky values and passion for our mission. If you're a dedicated healthcare professional who shares our vision for a better healthcare system, we encourage you to join our team.



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