Large managed care company looking for experienced RN's for their Continuous Care/Advanced Care program.  This will be a contract to permanent position for the right candidate.

RN II

Duties & Responsibilities: 

· Perform home and virtual visits with patients.

· Explore patients’ values and goals of care to ensure they are getting care and treatment that is in alignment with their goals.

· Facilitate advance care planning

· Coordinate with patient’s other providers including PCPs, specialists, and health plan case managers to ensure all are working together with the patients towards the same goals.

· Improve quality of life while addressing symptoms of serious illness in all domains, including physical, psycho-social, spiritual and cultural.

· Ensure patients are receiving optimal disease management to preserve organ function, thus helping to lengthen quantity of life

· Participate in an interdisciplinary (IDT) approach to care, MD, NP, RN and LPN, LCSW and chaplain support. This includes regular communication and coordination within the IDT.

· Working closely with members of our care team to ensure quality care is delivered in a timely manner. The care center will assist with scheduling and triaging of urgent issues.

· Working with field and office medical assistants.

· Clinical documentation of acute and chronic healthcare issues, symptoms, and goals of care through patient encounter in EMR system

· Documentation must be appropriate and thorough, and completed in a timely manner

· Ensure all appropriate consent forms are signed and dated

· The provider will educate patients and/or patient’s family on chronic medical conditions, preventative care, and medication adherence compliance

· Provider will participate in weekly telephonic clinical meetings and occasional web-based compliance trainings; however, provider will occasionally be required to attend on-site training for which the provider will be reimbursed

· RN will screen for ADL/IADL deficits, fall risk, depression, cognitive impairment and nutritional health.

· The RN will escalate issues that threaten patients’ well-being in the home

· Medication reconciliation done at every visit with a focus on reducing polypharmacy.

· The RN may also pass out home stool kits, and administer vaccines as needed.

· Performs other duties as assigned by the supervisor.

 Skills

· Nursing assessment, intervention and outcome evaluation experience and skills

· Palliative care skill set and experience

· Great customer service skills and patient advocacy

· Able to work well on a multidisciplinary team

· Tech/ EMR savvy

· Detail oriented and organized

 Education

· Minimum of 3-5 years of nursing experience as an R.N..

· Prior clinical experience in palliative care, end of life, hospice, oncology, ICU, geriatrics is preferred.

· Prior home based care experience is preferred

· Prior clinical experience in geriatric, adult or family medicine is preferred

·  Experience with electronic medical records is required. Also required is proficiency with various computer based applications such as Microsoft Office.

· Strong background/interest in primary care and preventative medicine

· Highly motivated, self-directed professional with strong organizational skills and comfortable working independently on a daily basis

· Excellent clinical assessment and analytical skills

· Effective leadership and interpersonal skills; facilitates problem resolution and maintains a professional demeanor in difficult situations.

· Excellent verbal and written communication skills

· Proven ability to pursue feedback, continuing education and professional development

· Candidates must have current in state of practice

· Specialty certification in Hospice and Palliative care desired (CHPN or ACHPN)

· Must have current BLS certification; ACLS preferred.

· Must have active/unrestricted license in state of position opening