Registered Nurse, CMS GUIDE Program, Delaware locations

ChristianaCare is currently seeking a Statewide Registered Nurse to support the CMS GUIDE program. The Statewide GUIDE Nursing Care Delivery Specialist is a registered nurse who provides clinical care coordination education and triage support across all three GUIDE program sites in Delaware. This role supports consistent delivery of CMS clinical care requirements while supporting care navigators and maintaining collaborative relationships with beneficiaries existing medical providers. This position requires regular travel to and service delivery at all three locations including Smyrna Rehoboth and Care Coordination (70%).

The Swank Center for Memory Care and Geriatric Consultation at ChristianaCare is Delawares first and most comprehensive outpatient office for patients with memory disorders and their families. The Swank Center for Memory Care and Geriatric Consultation offers these patient and their families essential support education and guidance from diagnosis through treatment.

Work Schedule

Monday-Friday 8:00am-4:30pm

Primary Function
The nurse will provide quality safe evidenced-based nursing care to achieve optimum outcomes both independently and as a valued team member of the practice. The nurse will follow the Nursing Process when providing patient care and be part of a multidisciplinary team serving patients enrolled in the Guiding an Improved Dementia Experience (GUIDE) Model Program.

Principal Duties and Responsibilities

• Demonstrates knowledge & skills necessary to provide care appropriate to adult and geriatric patients virtually or on-site within the practice including knowledge of growth development the ability to obtain and interpret information to identify patient needs and provide care needed
• Participates in a relationship-based care approach to care delivery
• Performs Nurse Visits such as Advance Care Planning Transitional Care Management and Medication Reconciliation.
• Triages patient telephone messages and ensures appropriate disposition under the direction of the provider
• Functions as a liaison between patients/caregivers physicians and staff to provide accurate communication
• Collaborates with team members to provide a smooth organized and efficient flow of patients
• Responds to patient crises situation
• Provides patient/caregiver education and wellness counseling
• Performs medication history
• Supports the work of the MA
• Assists with staff education and evaluation of clinical competencies for new and existing employees (MA)
• Assists with orientation of new personnel to ensure that they are properly trained to support patient and provider.
• Performs chart audits or has designee assist with chart audits
• Randomly shadows clinical support staff to ensure appropriate care is provided
• Supports the site by acting as the liaison for Joint Commission POCT Tracer monitor for Safe Practice Behavior Monitoring (SPBM) tools & Joint Commission Tracers
• Keeps current with policies and procedures and participates in quality improvement activities.
• Participates in special projects
• Performs assigned work safely adhering to established departmental safety rules and practices; reports to supervisor in a timely manner any unsafe activities conditions hazards or safety violations that may cause injury to oneself other employees patients and visitors.
• Performs other related duties as required
• Assists Nurse Navigator with coordination of care for Monoclonal AD Infusion cohort of patients
• Conducts comprehensive assessments of patients cognitive behavioral and physical health to tailor care plans effectively.
• Develops and maintains personalized care plans for dementia patients ensuring coordination with primary care providers specialists and community-based services.
• Provides education training and support to caregivers including coordinating with 24/7 access support line and respite services
• Regularly monitors patient progress and adjust care plans as necessary to meet evolving needs
• Will be required to make a minimum of one home visit as part of the GUIDE multidisciplinary team.
• Participates in multidisciplinary GUIDE team meetings and clinics

Education and Experience Requirements:

• A graduate of a state approved or National League of Nursing accredited School of Nursing
• RN license or eligible for licensure in the state Delaware
• Two years experience as a RN physician office experience preferred
• BSN preferred; ADN considered with agreement of completion of BSN in 3 years

Special Requirements:

• Current RN licensure in the state in which the work is performed
• BLS certification required

Qualified candidates should apply online and attach a copy of their current resume for consideration.

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Christiana Care Health System is an equal opportunity employer firmly committed to prohibiting discrimination whose staff is reflective of its community and considers qualified applicants for open positions without regard to race color sex religion national origin sexual orientation genetic information gender identity or expression age veteran status disability pregnancy citizenship status or any other characteristic protected under applicable federal state or local law.

Post End Date

EEO Posting Statement

ChristianaCare offers a competitive suite of employee benefits to maximize the wellness of you and your family including health insurance paid time off retirement an employee assistance program. To learn more about our benefits for eligible positions visit Experience:

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