Why Work for Us? Partners In Care (PIC) is an independent 501(c)(3) nonprofit organization and the largest, oldest provider of home health, palliative care, and hospice services in Central Oregon. Serving Deschutes, Crook, and Jefferson counties, our dedicated team of over 200 employees and 200 volunteers delivers compassionate, patient-centered care across a 10,000-square-mile area. Additionally, Hospice House in Bend, Oregon, is a specialty hospital for inpatient hospice care, creating an oasis of tranquility and comfort for patients and their families.
What You Get to Do: The RN Case Manager provides and coordinates home health care services for patients in their homes and facilities. This role focuses on delivering high-quality, cost-effective care with an emphasis on community health education. The RN uses organizational and community resources to support patients and families, ensuring positive health outcomes.
Complete an initial comprehensive (includes OASIS) and accurate assessment of the patient and family to determine home health needs. Provide a complete physical assessment and history of previous illness (es) and use the health assessment data to determine appropriate diagnosis and need for other disciplines and resources.
Develop an individualized care plan that establishes goals based on nursing diagnoses and incorporates therapeutic, preventive, and rehabilitative nursing actions. Include the patient and the family in the planning process. Make necessary revisions to the care plan as patient status and needs change. Complete and update the ongoing assessments and care plan as the patient’s status changes.
Initiate appropriate preventive and rehabilitative nursing procedures and treatments. Administer medications and treatments as prescribed by the physician.
Ensure that arrangements for equipment, other necessary items, and services are available.
Provide healthcare instructions and education to the patient and/or family as appropriate, per the assessment plan and the patient’s caregivers’ ability to learn. Adapt teaching styles to meet patients’ and families’ needs.
Identify discharge-planning needs as part of the initial care plan development and implement them before the patient's discharge.
Develop, monitor, and update the HCA plan of care as necessary, including completion of HCA supervisory visits every 14 days. The HCA plan of care is complete, accurate, and updated regularly, typically at every certification or as the patient's needs change.
Update the primary physician when necessary and at least every sixty days.
Communicate with the physician regarding the patient’s needs, reports, and changes in the patient’s condition; obtain/receive physician’s orders as required.
Communicate with all members of the healthcare team to promote coordinated, efficient care and document the coordination of care with all individuals involved in patient care.
Initial assessments are complete, accurate, and submitted within 48-72 hours of admission. Additionally, ongoing clinical documentation is complete, accurate, documented, and submitted within 24 hours of the patient visit.
Participate in weeknight and weekend on-call duties as defined by the on-call policy.
Adhere to the PIC mission and values.
Required Skills & Qualifications:
Graduate of an accredited school of nursing with current licensure to practice professional nursing in the State of Oregon.
Excellent assessment, problem-solving, and nursing skills, as per the competency checklist.
Strong clinical judgment and patient triaging skills are vital; efficient time management with minimal oversight; communication skills (with other care team members, including physicians); positive phone interaction/customer service; and computer skills.
One to two years of recent medical/surgical care experience in an institutional setting.
Ability to pass a background test, drug screen, and TB test.
Ideal candidates will possess 1-2 years of home health experience.
Valid CPR Certification.
Current automobile insurance, a valid Oregon driver’s license, and reliable transportation are required for those working in the field.
Strong communication and interpersonal skills.
Ability to work independently and collaboratively within an interdisciplinary team.
Compassion, empathy, and dedication to patient care.
Travel- Local/regional travel by personal vehicle during the working day. Mileage reimbursement is provided.
Company Perks:
Two Medical/Dental Plans, including vision.
Generous Paid time off.
$25,000 life insurance policy.
Short and long-term disability.
403b retirement savings with employer match, no vesting required!
Employee Assistance Program