AIM Telesupport RN On any given day, Sutter Care at Home (SCAH) touches the lives of thousands of individuals by bringing health care directly to our patient's home - where most people chose to receive their care.Sutter Care at Home is one of the largest not-for-profit home health care and hospice agencies in Northern California. Founded in 1906, SCAH is committed to compassion and excellence through home health care, hospice, home medical equipment and respiratory care, home infusion therapy, private and geriatric care, Lifeline medical alert services and community flu and wellness programs. Serving more than 150,000 patients in 23 counties each year, Sutter Care at Home clinicians partner with our patients for better health.Through competitive wages and benefits, flexible schedules, innovative care models, new technologies, and tuition reimbursement - Sutter Care at Home strives to be your "employer of choice." Sutter Care at Home is the home health care and hospice affiliate of Sutter Health, one of the nation's largest not-for-profit health care systems. The AIM Telesupport RN has the responsibility to identify, plan, coordinate ,implement, monitor and evaluate appropriate healthcare for patients enrolled in the Advanced Illness Management Program. The AIM Telesupport RN provides for optimal outcomes through collaboration with the patient, the family , the physician and other members of the AIM team. The AIM telesupport RN enters referrals into Epic Electronic Medical Record. (and completes referral process and admits patient as appropriate. Once patients are enrolled, the AIM Telesupport RN assists the care team with patient education and coaching, begins advanced care planning, provides transition of care interventions, and coordinate with the Home health care team for Home health needs, including facilitating orders, assessing patient needs, including care goals, level of care, DME, comfort medications and transportation. Education Bachelor Degree required. Graduate from an accredited school of nursing with a current California Registered Nursing license. California Public Health Certificate or completion of Community Health Nursing program preferred. Experience Minimum one year Case Management, Hospice and/or Home health experience. Recent experience in acute-care hospital setting; knowledge of discharge planning/case management strongly preferred. Experience in developing care plans, working as a member of a multi- disciplinary team, telephone patient case management, knowledge of health related information education, resource and referral services. Experience providing patient education and self-management support. Knowledge Possess critical thinking skills, in-depth knowledge of clinical disease entities common to hospice and palliative care for terminally ill patient. General Knowledge of common diagnoses and procedures, working knowledge of current treatments and their physical and psychosocial sequelae, knowledge of the influence of cultural and spiritual values on health care, must know elder and dependent adult and domestic violence reporting requirements, general knowledge of available healthcare and community resources appropriate for populations served. Knowledge of chronic disease processes. Should also possess knowledge of hospice reimbursement methods. Skills Must have the ability to function independently and as a member of an interdisciplinary team; ability to exercise independent, sound nursing judgment in planning and providing patient care. Ability to recognize the special needs of Hospice patients and others in the home. Ability to communicate with patients and significant others in an effective, mature, caring manner. Ability to maintain harmonious constructive relationships with internal and external customers. Must have the ability to work in a high volume case load and deal effectively with rapidly changing priorities, strong clinical assessment and critical thinking skills to develop a comprehensive plan of care appropriate to patients with complex medical, emotional and social needs. Must show demonstrated skills in motivating, mentoring, coaching and redirecting clients in order to achieve compliance with various necessary medical, social and functional interventions. **Primary Location: **Utah-Salt Lake City-Salt Lake City **Work Locations: ** **Organization: **Sutter Medical Center, Sacramento