Palliative RN Case Manager

Desert Oasis Healthcare; Palm Springs (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Desert Oasis Healthcare seeks a skilled Palliative RN Case Manager to join the interdisciplinary team in Palm Springs, CA. You will identify physical, emotional, and social needs of patients and families, initiating interventions and providing a comprehensive care plan.

You will manage a caseload, conduct initial and ongoing assessments, coordinate services, educate patients and families, document accurately, and collaborate with physicians and team members to ensure high-quality end-of-life

Qualifications

• Current/valid Registered Nurse licensed in the State of California.
• Minimum of 1 year of professional nurse experience within the last 3 years with CA RN license.
• Hospice or home health experience preferred.
• Knowledge of the principles and practices of primary medical and nursing care.
• BLS certification within 60 days of hire; strong listening and communication skills.
• Able to multitask effectively and function in an IDT.
• Valid California driver’s license with proof of insurance; travel required.

Responsibilities

• Provide direct patient care per the State Nurse Practice Act and agency policies.
• Oversee a caseload and anticipate crises to reduce unnecessary utilization.
• Perform thorough initial and ongoing assessments to determine appropriate care plans.
• Update and revise the plan of care in consultation with physicians and team members; communicate changes.
• Coordinate medical services and refer to specialized programs and services as needed.
• Re-evaluate patient needs and address changes with the team; address 5 STAR measures as appropriate.
• Educate patients and families about diagnosis and self-care plans.
• Discuss POLST/DPOA with new patients and provide ongoing education.
• Document accurately and timely; participate in team meetings and in-services.
• Assist in orientation of new staff and provide holiday coverage as needed.

Skills

Communication skills

Multitasking

Interdisciplinary teamwork

Travel availability

Job description

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%.