Virtual Assistant US Nurse (Office-Based)

Job description:

Remote Telehealth Registered Nurse – ALW/CCT Program

Job Summary

The Remote Telehealth Registered Nurse for the ALW/CCT Program is responsible for conducting nursing assessments, reassessments, monthly monitoring visits, and care coordination for participants enrolled in the Assisted Living Waiver and/or California Community Transitions programs.

This is a remote telehealth position. The RN will conduct assigned visits by telephone and/or audio-video telehealth platforms, complete required documentation, identify participant needs and safety concerns, and coordinate with program staff, participants, families, caregivers, facilities, and community providers as needed.

The RN must be able to work independently, use sound clinical judgment, complete documentation accurately and timely, and escalate clinical or safety concerns appropriately.

Essential Duties and Responsibilities

The Remote Telehealth RN’s responsibilities include, but are not limited to:

Telehealth Assessments and Reassessments

• Conduct initial nursing assessments for ALW and/or CCT participants as assigned.
• Complete participant reassessments by telehealth to evaluate current health status, functional needs, medical concerns, safety risks, and support needs.
• Assess participant’s medical history, diagnoses, medications, ADLs, mobility, cognition, fall risk, skin concerns, nutritional status, psychosocial needs, caregiver support, and environmental safety concerns to the extent possible through telehealth.
• Ask appropriate follow-up questions to identify changes in condition, unmet needs, or risks that may require further evaluation.
• Recognize when telehealth assessment is not sufficient and escalate the need for in-person follow-up, provider evaluation, emergency care, or supervisor review.
• Document all assessment findings clearly, accurately, and within required timelines.

Monthly Telehealth Visits and Monitoring

• Complete monthly monitoring visits as assigned.
• Conduct visits remotely by telephone and/or audio-video telehealth platform.
• Monitor participant status, including any changes in condition, ER visits, hospitalizations, falls, medication concerns, wounds, behavioral concerns, caregiver issues, or changes in living situation.
• Confirm services and supports are being provided as planned.
• Identify and report unmet needs, barriers to care, or participant safety concerns.
• Follow up with participants, caregivers, facilities, and program staff as needed.
• Document each monthly visit and all follow-up actions timely and accurately.

Care Coordination

• Coordinate with participants, families, caregivers, assisted living facility staff, physicians, home health agencies, hospice agencies, pharmacies, DME providers, discharge planners, and other community providers as appropriate.
• Assist with care coordination related to participant stability, safety, and continued community placement.
• Communicate significant health changes or concerns to the appropriate supervisor, case manager, physician, facility staff, or care team member.
• Support transition planning and post-transition monitoring for CCT participants as assigned.
• Help ensure services are coordinated to support participant needs and prevent avoidable complications, hospitalizations, or placement issues.

Documentation and Compliance

• Complete all required ALW/CCT nursing documentation accurately and timely.
• Document assessments, reassessments, monthly contacts, care coordination activities, participant concerns, clinical findings, and follow-up actions.
• Ensure documentation supports participant needs, safety concerns, and services provided.
• Maintain documentation in accordance with agency policies, program requirements, HIPAA, and applicable state and federal regulations.
• Submit completed documentation by assigned deadlines.
• Maintain confidentiality of participant information while working remotely.

Remote Work and Telehealth Requirements

• Maintain a private and professional remote work environment.
• Ensure participant privacy during all phone and video encounters.
• Verify participant identity as appropriate before discussing health information.
• Use agency-approved systems for documentation, communication, and telehealth visits.
• Maintain reliable internet, phone access, and ability to use required electronic systems.
• Keep all participant records and electronic information secure.
• Notify supervisor promptly of techni…