Registered Nurse Case Manager - Hospice

Pathways Home Health, Hospice and Private Duty•Sunnyvale, CA

1d•$57 - $78

About The Position

For over 45 years Pathways has been a Bay Area pioneer, leader, and innovator in Hospice, Home Health and Palliative Care. We provide care at home or in settings such as assisted living, a nursing home, or the hospital. We have offices in Sunnyvale, South San Francisco, and Oakland. Patients and their families know us for our personalized, high-quality care, delivered with empathy, kindness, and respect. POSITION SUMMARY: The Hospice Nurse admits patients to service, assesses the patient’s and family’s physical, psychosocial, environmental, safety and developmental needs. They develop an individualized plan of care based on their assessment and document their observations and interventions related to the patient's environment. This role coordinates care with a multidisciplinary team, participates in the hospice program's quality assessment performance improvement program and conducts follow up visits as needed.

Requirements

Current California RN license
Minimum of one year of nursing experience required
Current CPR Certificate
Current California driver's license and automobile insurance

Responsibilities

Performs an initial, comprehensive assessment.
Documents observations, clinical findings, problems, skilled interventions, goals and discharge plans
In consultation with the assigned Clinical Team Manager, initiates and regularly re-evaluates and revises plan of care.
Assesses the need for the services of other team members (PT, OT, ST, MSW and HHA).
Provides and documents skilled care on all visits (includes skilled observation of the patient's condition, skilled care and procedures and teaching of the patient and/or family).
Obtains and documents physician orders.
Performs Home Health Aide supervisory visits per regulatory requirements.
Coordinates care with the assigned Clinical Team Manager, physician and other members of the home care team, informing them of significant changes in the patient’s condition and needs. Documents these communications.
Follows established standards for point of service technology, documentation and synchronization.
Submits weekly visit schedule of assigned patients. Collaborates with Clinical Team Manager to address scheduling needs.
Performs re-certifications, resumption of care, transfers and discharges as requested by the assigned Clinical Team Manager. Completes and submits all related documentation.
Attends and actively participates in the clinical team multidisciplinary patient conference.
Demonstrates established clinical competencies.
Participates in agency sponsored in-service education.
Participates in quality improvement activities.
Assists in development of agency protocols, procedures and policies as requested.
Assesses, develops, organizes and delivers teaching materials for assigned home care patients as appropriate.