Care Coach Connect RN Case Manager Midland, TX and Surrounding Cities
4 days ago
- Conducts medical home visits on established Care Coach Connect patients performing a hands on exam at each visit
- Conducts urgent/acute visits on established Care Coach Connect patients with the goal of keeping the patient out of the hospital in order to receive the best medical care at home
- Provides ongoing assessments of the impact of life-limiting and/or chronic illness(es) on the patient's physical, functional, psychosocial and environmental needs
- Assess for caregiver burnout, and provide community resources when appropriate
- Implement the individualized plan of care and recommend revisions to the plan as necessary
- Ability to perform procedures, to include, but not limited to: a. Wound care and dressing change b. Phlebotomy c. injection (B12, vaccines)
- Ability to conduct an advanced care discussion with a patient and their family and properly document their wishes in the electronic medical record. Consults and educates the patient/family and other caregivers regarding the disease process, pain and symptom management, end of life care and processes for dealing with issues of ethical concern
- Initiates appropriate preventive and rehabilitative nursing procedures when appropriate
- Ensure continual assessment of patient and family needs from admission to Care Coach Connect throughout the course of care
- Provides ongoing evaluation of the patient and family/caregiver response to care, and recommends alteration of the plan when necessary. 12. Attends the interdisciplinary meeting and is a crucial and vocal member of the team
- Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. Decision making is usually based on prior practice or policy, with some interpretation. Applies individual reasoning to the solution of a problem devising or modifying processes and writing procedures
- Conducts telephonic nursing follow up and case management when necessary
- Serves as a resource or consultant for LVN/MA
- Attends educational offerings to keep abreast of chronic medical conditions and complies with licensing requirements
- Establishes a trusting relationship with identified patients, caregivers, clinic staff members and Providers
- Collaborates with the providers to recommend policies, procedures and standards which affect the care of the Care Coach Connect Patient
- Exhibits professionalism and is courteous with all patients, physicians and co-workers
- Informs the provider of patient's needs and outcomes of interventions as per standards
- Follows Care Coach Connect providers' orders regarding the scope and frequency of services needed based on acuity and patient/family needs
- Coordinates all patient/family services and prioritization of needs with the members of the interdisciplinary team
- Documents in the electronic health record progress toward established goals as per standards
- Uses the case management approach and refers to other services as needed
- Maintains a patient case load, daily visits and point of care documentation levels as per standards
- Performs all other related nursing duties as assigned
- Registered Nurse with a current license to practice in the state of employment
- Current BLS certification or must obtain certification within 30 days of employment hire date
- 3+ years of experience in a physician's office, clinical, hospice or hospital setting
- Demonstrate experience of excellent nursing skills
- Proficient computer skills, including Microsoft Word, Excel, Access and Outlook
- Demonstrate ability to interact productively with individuals and with multidisciplinary teams
- Have reliable transportation for daily travel to various locations as assigned, up to 80% of the time
- Valid driver's license within the state of work
Preferred Qualifications:
- Hospice and Palliative Care Nursing certification
- 2+ years of hospice experience
- Experience with home visits
- Experience related to advanced care planning and discussions with patients regarding end-of-life wishes
- Experience with community-based nursing
- Knowledge of palliative and hospice medicine
- Bilingual (English/Spanish) language proficiency
- Proven excellent verbal and written skills
- Proven excellent organizational and prioritization skills
Physical & Mental Requirements:
- Ability to lift up to 100 pounds Ability to push or pull heavy objects using up to pounds of force
- Ability to sit for extended periods of time
- Ability to stand for extended periods of time
- Ability to use fine motor skills to operate office equipment and/or machinery Ability to properly drive and operate a company vehicle
- Ability to receive and comprehend instructions verbally and/or in writing Ability to use logical reasoning for simple and complex problem solving
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