About the role
Overview
We are seeking a highly skilled RN or LPN to serve as the remote support hub for our in-house Nurse Practitioners (NPs) practicing in Skilled Nursing Facilities (SNFs) as a Remote Clinical Support Nurse.
The Clinical Support Nurse coordinates care for high-risk residents in SNF and ALF settings. This role partners with physicians, nurse practitioners, nursing leaders, residents, families, specialists, pharmacies, and community providers to prioritize clinical needs, close communication gaps, and support safe transitions of care.
Role Scope
Post-acute and long-term care residents in SNF/ALF settings.
Daily clinical navigation from admission through discharge.
Close collaboration with facility and provider teams.
Primary Objectives
Surface risk early: Review clinical information and direct provider attention to residents with the greatest needs.
Close care gaps: Track consultations, laboratory results, orders, records, medications, and follow-up activities through completion.
Prepare the care team: Coordinate schedules and pre-chart relevant information for efficient, informed visits.
Keep people connected: Provide routine updates and promptly escalate acute, complex, or change-of-status concerns.
Why You'll Love This Role
High Visibility & Strategic Impact: This role isn't just a support function; you'll be a key partner in building, refining, and scaling this program, with a direct line to company leadership.
True Work-Life Balance: This is a fully remote, Work-From-Home position with the flexibility to manage your own schedule and day.
Be a Pioneer: You get to be on the ground floor of a high-impact program. You'll help create the playbook, refine workflows, and have a tangible impact on the program's success as it scales.
Meaningful Growth: We are committed to your professional development, with opportunities to expand your licensure and grow alongside the program.
HealthDrive delivers on-site dentistry, optometry, podiatry, audiology, behavioral health, and primary care services to residents in long-term care, skilled nursing, and assisted living facilities. Each specialty offered by HealthDrive is one that directly impacts the quality of daily life for the deserving residents we serve. HealthDrive connects patients in need of vital healthcare to doctors committed to dignity and excellence.
Responsibilities
Clinical Review and Provider Readiness
Review overnight nursing logs, emergency-department notices, clinical records, and daily risk reports to identify instability and prioritize high-risk residents.
Build and maintain provider schedules for high-risk residents, new admissions, planned discharges, regulatory visits, and follow-up care.
Pre-chart diagnoses, functional status, recent events, laboratory results, medications, consultation findings, and outstanding actions.
Consultations and Clinical Follow-Through
Coordinate specialist appointments, transportation, communication, and receipt of consultation notes.
Track consultant recommendations and promptly route therapy, procedure, or order changes to the physician, nurse practitioner, and facility team.
Retrieve and integrate HIE information, emergency-visit records, discharge summaries, outside consultations, laboratory results, and other provider records into the appropriate clinical system.
MDS/PDPM Coordination
Partner with facility MDS coordinators to schedule provider visits and ensure functional and diagnostic conditions are comprehensively captured.
Prepare clinical information supporting accurate MDS/PDPM documentation without placing additional administrative burden on the rounding provider.
Team Alignment and Documentation
Communicate with nursing leadership, unit managers, collaborating clinicians, and facility staff to clarify priorities and next steps.
Complete timely documentation and confirm that provider orders are entered into the facility EMR.
Coordinate controlled-substance renewal scheduling as assigned.
Discharge and Community Transition
Coordinate discharge visits so provider assessments and documentation are completed before residents leave the facility.
Schedule timely community PCP follow-up appointments.
Communicate care plans, medications, and next steps to residents, families, pharmacies, and community partners.
Oversee prescription ordering and pharmacy fulfillment to support medication availability at home.
Medication and Laboratory Safety
Reconcile facility, provider, and discharge medication lists and resolve discrepancies with the appropriate clinician.
Review medication lists for deprescribing opportunities and escalate concerns involving polypharmacy, side effects, or interactions.
Identify missing outside laboratory results and ensure they are available for clinical review.
Resident and Family Communication
Provide proactive, compassionate updates regarding stable progress, routine results, therapy milestones, and transition plans.
Serve as a consistent point of contact for residents and families.
Promptly escalate acute changes, complex clinical questions, and sensitive conversations to the physician or nurse practitioner.
Advance Care Planning Support
Identify residents experiencing clinical deterioration who may benefit from advanced care planning or palliative-care evaluation.
Coordinate with qualified providers on goals-of-care discussions, POLST documentation, symptom-management planning, and family education.
Qualifications
Active, unencumbered Nursing license in the applicable state or states of practice. Connecticut/Rhode Island/Compact Licensure.
Clinical nursing experience in post-acute care, long-term care, geriatrics, transitions of care, or care management.
Strong clinical assessment, prioritization, medication reconciliation, documentation, and care-coordination skills.
Ability to use EMRs, HIEs, scheduling tools, and secure communication channels.
Working knowledge of MDS/PDPM, discharge planning, advance directives or POLST, privacy requirements, and professional scope of practice.
Originally posted on Himalayas