Description
**Organization:**
SCAH-Sutter Care at Home - Valley
**Position Overview:**
Advanced Illness Management (AIM) Transitions/Telesupport RN Care Coordinator - Hybrid position Requiring Home-based care delivery and virtual care delivery. The AIM Transitions RN Care Coordinator (RNCC) provides specialized nursing services to patients nearing the end of life. The Transitions/Telesupport Nurse manages a caseload of patients with advanced illness who are participating in the AIM Program. The Transitions/Telesupport Nurse provides care both in the home and through telephone support. He or She works within the 6 pillars of the AIM Program. The care provided focuses on care coordination, patient-coaching and decision-support, symptom management, advanced care planning, education relating to disease process and treatment options, psycho-social and spiritual care, and reduction of Emergency Room (ER) visits, inpatient hospitalizations, and timely transition to hospice. Other duties associated with the AIM program will be assigned as needed.
**Job Description** :
**EDUCATION**
Graduate of an accredited school of nursing. Bachelor's degree in nursing preferred.
**CERTIFICATION & LICENSURE**
RN-Registered Nurse of California
BLS-Basic Life Support Healthcare Provider
California Driver's License
Valid Auto Insurance
**PREFERRED EXPERIENCE AS TYPICALLY ACQUIRED IN:**
5 years' experience in a home health and/or hospice position preferred.
One year of acute medical experience required.
Oncology or palliative care experience desirable.
Direct patient care experience within the past five years required.
Excellent clinical, critical thinking and assessment skills
Good interpersonal skills
**KNOWLEDGE:**
Demonstrated proficient knowledge and competence regarding nursing theories, concepts, and practices; medical terminology; anatomy; and physiology.
Understanding of home care and hospice services and regulations, Title XXII, Medicare Conditions of Participation; infection control principles; excellent working knowledge of the principles of palliative care and demonstrated ability to work with patients with advanced illness.
Working knowledge of the healthcare industry, safety precaution policies, best practices regarding patient care and privacy, and changes in local/state/federal regulations.
**SKILLS:**
Complete AIM program training. Successfully pass AIM Program competency exam on annual basis with demonstration of knowledge in symptom management, understanding end of life issues with appropriate interventions and understanding of the impact of cultural background on illness management.
Possess excellent interpersonal skills enabling the AIM Program RN to discuss difficult issues
concerning clinical goal setting and transition toward end-of-life care with patients, families and
physicians.
Be a self-starter with a high degree of initiative, motivation, flexibility, energy, and creativity.
Ability to work as part of an interdisciplinary team as well as form harmonious working relationships with internal and external customers.
Excellent collaborative and problem-solving skills with customers and management.
Ability to exercise independent sound judgment in planning and providing patient care. Demonstrated ability in physical, psychosocial, and environmental assessment skills and in implementing plan of treatment.
Possess written and verbal communications skills to explain sensitive information clearly and professionally to diverse audiences, including non-medical people.
Proficient knowledge of computer applications, such as Microsoft Office Suite (Word and Outlook, Excel, Teams), Electronic Health Record.
Time management and organizational skills, including the ability to prioritize patient care, assignments and work within standardized policies, procedures, and practices to achieve objectives and meet time sensitive activities.
Prioritize assignments and work within standardized policies, procedures, and scientific methods to achieve objectives and meet
Prioritize assignments and work within standardized policies, procedures, and scientific methods to achieve objectives and meet deadlines.
Work independently, as well as be part of the team, including accomplishing multiple tasks in an environment with interruptions.
Identify, evaluate, and resolve standard problems by selecting appropriate solutions from established options.
Ensure the privacy of each patient's protected health information (PHI).
Build collaborative relationships with peers and other healthcare providers to achieve departmental and corporate objectives.
**Essential job duties and physical demands include and are not limited to:**
Administers nursing patient care in a home; be able to remain sedentary for approximately 50% of the day, maneuver around objects, climb stairs and/or work in relatively small spaces, bend over or stretch as necessary in care provision, operate telephone and manipulate small clerical items (e. g. paperclips, staples, etc.); ability to raise, lower, or transfer objects and supplies from one level to another; transport an object usually by hands, arms or shoulders; ability to bend, stoop, twist and lift and transfer up to 50 pounds in patient care.
Must be able to meet company productivity standards as indicated by organization. Must be able to hear, read, write, and speak clearly to effectively communicate with department staff, other Sutter Care at Home employees, community, and patients to carryout essential functions.
Must be able to deal with challenging work environment with time demands and occasional conflicting priorities. Maintain a positive and professional image and demonstrate self-directed learning to meet professional development and/or license requirements. Is responsible for maintaining all required licensure and certifications. At orientation and annually thereafter, must be able to meet AIM core competencies for position and area of specialty, as appropriate.
**PRINCIPLE ACCOUNTABILITIES:**
The Transitions Nurse -AIM Program performs general nursing clinical procedures which may include care coordination, patient coaching and decision-support, symptom management, psycho-social and spiritual care, advanced care planning, education of disease process and treatment options, resulting in reduction of ER visits and timely transition to hospice
**Primary Job Responsibilities:**
utilizes effective physical and psychosocial assessment skills, performs and documents multi-system assessments
determine red flags for individual patients with appropriate crisis plans to ensure patient and family
Compensation Information:
$0.0 / - $0.0 /
Starting At: 0.0
Up To: 0.0
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