RN Case Manager

This is a full-time position within our palliative department and involves utilizing reliable transportation to go to participant's homes.

Job Summary: Under the direction and supervision of the Director of Clinical Services, the Palliative case manager plans, organizes and coordinates palliative care services. The nurse demonstrates detailed nursing assessments skills, including a comprehensive nursing evaluation and interaction with participants as needed in their home environment. Participates in planning, executes interventions in accordance with the goals of care and contributes to the evaluation of individualized interventions related to the goals of care. Coordinates with the interdisciplinary team to develop a comprehensive goal of care for each client. Administers medications, implements primary care orders, and evaluates participant complaints physically or by phone and report findings to the physician. Provides education to participants and caregivers in regard to goals of care, nursing treatments or medications. Communicates participant’s condition to primary care givers, physician and multidisciplinary team.

Duties and Responsibilities:

Patient Care

Completes an initial and ongoing comprehensive evaluation of patient and family to determine palliative needs. Provides a complete physical evaluation and history of current and previous illness(es).
Provides professional nursing care by utilizing all elements of nursing process and as defined in the state Nurse Practice Act.
Evaluates patient’s status by regularly re-evaluating patient and family/caregiver needs, and participating in revising the goals of care as necessary
Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
Counsels the patient and family in meeting nursing and related needs.
Provides health care instructions to the patient as appropriate.
Assists the patient with working toward self-sufficiency and optional comfort care.
Acts as Case Manager as assigned and assumes responsibility to coordinate patient care for assigned caseload.

Communication

Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.
Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary team.
Provides and maintains a safe environment for the patient.
Assists the patient and family/caregiver and other team members in providing continuity of care.
Works in cooperation with the family/caregiver and palliative interdisciplinary team to meet the emotional needs of the patient and family/caregiver.
Attends interdisciplinary group meetings.
Reviews LVNs documentation for accuracy and timeliness in accordance to our policies and procedures

Additional Duties

Oversee admissions to the palliative care program and coordinate referrals to outside agencies.
Participates in on-call duties as defined by the on-call policy.
Ensures that arrangements for equipment and other necessary items and services are available.
Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
Fulfills the obligation of requested and/or accepted case assignments.
Actively participates in quality assessment performance improvement teams and activities.
Performs other duties and assignments as assigned

Qualifications and Requirements:
Education:

Graduate of an accredited school of nursing.
Current California RN licensure and CPR certification.

Experience:

One (1) to two (2) years of recent acute care experience in an institutional setting, and one (1) to two (2) years of recent experience in home care.