RN Case Manager

St. Paul's Senior Services•San Diego, CA

4d•$40 - $59•Hybrid

About The Position

San Diego’s St. Paul's PACE program (Program of All-Inclusive Care for the Elderly) is seeking an RN Case Manager for their palliative department. This innovative program serves individuals 55 years or older who are living with chronic illness or disabilities and require coordinated medical care to maintain independence in their home and community. The healthcare teams at St. Paul’s PACE provide a hands-on approach, coordinating medical, social, and home care services. This is a full-time position that requires utilizing reliable transportation to visit participants in their homes.

Requirements

Graduate of an accredited school of nursing.
Current California RN licensure and CPR certification.
One (1) to two (2) years of recent acute care experience in an institutional setting.
One (1) to two (2) years of recent experience in home care.
Must be able to clear fingerprints through DOJ and FBI.
Must be able to clear a drug screen.

Responsibilities

Plans, organizes, and coordinates palliative care services under the direction and supervision of the Director of Clinical Services.
Performs detailed nursing assessments, including comprehensive nursing evaluations and interactions with participants in their home environment.
Participates in planning and executes interventions aligned with the goals of care.
Contributes to the evaluation of individualized interventions related to the goals of care.
Coordinates with the interdisciplinary team to develop a comprehensive goal of care for each client.
Administers medications and implements primary care orders.
Evaluates participant complaints physically or by phone and reports findings to the physician.
Provides education to participants and caregivers regarding goals of care, nursing treatments, or medications.
Communicates participant’s condition to primary caregivers, physicians, and the multidisciplinary team.
Completes an initial and ongoing comprehensive evaluation of patient and family to determine palliative needs.
Provides a complete physical evaluation and history of current and previous illness(es).
Provides professional nursing care utilizing all elements of the nursing process as defined in the state Nurse Practice Act.
Evaluates patient’s status by regularly re-evaluating patient and family/caregiver needs, and participating in revising the goals of care as necessary.
Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
Counsels the patient and family in meeting nursing and related needs.
Provides health care instructions to the patient as appropriate.
Assists the patient with working toward self-sufficiency and optional comfort care.
Acts as Case Manager as assigned and assumes responsibility to coordinate patient care for assigned caseload.
Completes, maintains, and submits accurate and relevant clinical notes regarding patient’s condition and care given.
Records pain/symptom management changes/outcomes as appropriate.
Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
Teaches the patient and family/caregiver self-care techniques as appropriate.
Provides medication, diet, and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers.
Works in concert with the interdisciplinary team.
Provides and maintains a safe environment for the patient.
Assists the patient, family/caregiver, and other team members in providing continuity of care.
Works in cooperation with the family/caregiver and palliative interdisciplinary team to meet the emotional needs of the patient and family/caregiver.
Attends interdisciplinary group meetings.
Reviews LVNs documentation for accuracy and timeliness in accordance with policies and procedures.
Oversees admissions to the palliative care program and coordinates referrals to outside agencies.
Participates in on-call duties as defined by the on-call policy.
Ensures that arrangements for equipment and other necessary items and services are available.
Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
Fulfills the obligation of requested and/or accepted case assignments.
Actively participates in quality assessment performance improvement teams and activities.
Performs other duties and assignments as assigned.