Palliative RN Case Manager

Description The Palliative RN Case Manager is the member of the interdisciplinary team who is the pivotal person in identifying the physical, psychological and social needs of the patient and their family/caregivers. He/She initiates appropriate intervention and support for the patient and family/caregivers, and provides an appropriate, comprehensive and responsive plan of care on an ongoing basis. ##### Professional Duties - Provides direct patient care as defined by the State Nurse Practice Act and agency policies. - Effectively oversees and manages a caseload of patients. Able to anticipate or identify any potential crisis situation in order to decrease or prevent any unnecessary utilization. - Completes a thorough initial and ongoing assessments to determine an appropriate plan of care related to their: diagnosis, treatment plan, functional status, acuity score and any other pertinent information gathered from assessment(s). Each visit should also incorporate a medication reconciliation as appropriate. - Plan of care is updated and revised in consultation with the physician, practitioner and/or other team members as appropriate. Assures changes in the plan of care is communicated to the patient and/or family/caregiver and other team members as appropriate. - Participates in coordination of medical services and appropriately reporting identified needs to Clinical Resource Supervisor/Director and/or practitioner to assure appropriate referrals are generated. This includes appropriate referral for a specialized program, PT, OT, MSW, ST, Dietician, DME and/or any other service available by DOHC. - Re-evaluates patients needs and conditions as necessary and consults with Clinical Resource Supervisor/Director of PC, and/or practitioner regarding any changes in condition and facilitates communication. This includes assuring HCC codes and 5 STAR measures are addressed as appropriate. - Assess and provide patient and family/caregiver education and information pertinent to diagnosis and self-plan of care in a method that is understandable to patient and family/caregiver. - Address POLST and DPOA with each new patient and engage in the Serious Illness Discussion as appropriate. Provide ongoing education and teaching pertinent to diagnosis and self-plan of care in a method that is understandable to patient and family/caregiver. - Provides accurate and timely documentation consistent with the plan of care; this may include preparing clinical and other progress notes as appropriate. - Participates in team meetings (IDGs) and in-service programs as required. - Participates in the orientation of new team members as assigned by the Clinical Resource Supervisor/Director of PC. - Participates in holiday coverage as needed. - Engage in the Serious Illness Discussion with each new patient, address POLST and DPOA as appropriate. - Performs other duties as assigned. - Be accountable for your work - Speak positively about your work, co-workers and Desert Oasis Healthcare and Family Hospice Care - See the positive in situations and in others - Inform patients and co-workers of how and when to contact you under normal circumstances (phone number, email, a help line, Immediate Care, etc.) or when unforeseen issues arise ##### Qualifications - Current/valid Registered Nurse licensed in the State of California. - Registered Nurse shall have a minimum of (a) one (1) year experience as a professional nurse within the last (3) years and holds a current CA RN license. Previous experience in hospice or home health preferred. - Knowledge of the principles and practices of primary medical and nursing care. - BLS required within 60 days of hire. Demonstrates the ability to use good listening and communication skills. - Able to multi-task effectively. - Capacity to relate and work as a member of an IDT. - Current California driver's licens and proof of insurance. - Travel required. ##### Physical Demands Type Description Sitting Approximately 60% of day Standing Approximately 20% of day Walking Approximately 20% of day Lifting 0 - 40 lbs - approximately 20% of day Bending Approximately 10% of day. Kneeling < 20%. Hearing/Visual Acuity Adequate for use with computers, telephone and or Blackberry - Approx 50% of day Computer Highly technical work environment - Must be able to work = 4 hours / day using keyboard, mouse and monitor Reaching Above head 75 degrees - approximately 25%.