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ACO - RN Palliative Care Case Manager

Millennium Physician Group Fort Myers, FL
  • Posted: over a month ago
  • Full-Time
Job Description: SummaryThe RN Palliative Care Case Manager is responsible for care coordination of specialized medical care for people living with serious, often life limiting, illness. The Palliative care nurse will provide an integrative and multidisciplinary treatment approach that helps patients maintain physical, mental, emotional, and spiritual health. Care is focused on alleviating symptoms related to disease which may include but are not limited to pain, chronic fatigue, anxiety, depression, and muscle weakness. The care plan focus is on relief of symptoms as opposed to curing disease. The Palliative Care RN Case Manager is focused on patient centered services that link patients and other family members with health care, psychosocial and other home and community-based services to ensure timely, coordinated access to medically appropriate levels of health and support services and continuity of care. S/he is responsible for assessment, planning, coordination, advocacy, education, monitoring and accurate, timely documentation in all program areas. The goal of care is to increase a sense of wellbeing; decrease physical, emotional, and mental distress; address issues related to chronic illness; provide for the spiritual needs of the patient, and improve the quality of life for both the patient and caregiver(s)/family.Essential Duties and Responsibilities include the following. Other duties may be assigned.Conducts comprehensive assessments that identify behavioral, clinical, emotional, social, and environmental concerns and needs of the patient.Demonstrates ability to work with the patient, caregiver(s), patient's physician, palliative care APRN, and other members of the health team, to create a care plan with focus on alleviation and management of symptoms related to the disease process; addresses the identified needs; removes the barriers for implementation of the plan; and improves the quality of life for the patient and caregiver(s).Assists patient/caregiver with completion of Advanced Directives / Advanced Care Planning.Provides education to the patient and family of the benefits of Hospice Care and when such intervention might be beneficial and appropriate. Assists with referrals as indicated.Provides regular outreach to the patient, reviews/modifies care plan as indicated, provides education on symptom management, coordinates care with all members of the patient's healthcare teamCoordinates/collaborates with the social worker to obtain assistance with local community and government resources for patients and their families and helps facilitate the patient's access to these resources. Coordinates/collaborates with LCSW as indicated for assistance with behavioral health and emotional support needs.Coordinates/collaborates with designated clergy for spiritual support, care and counseling.Assesses the patient/caregiver's knowledge of their clinical condition and provides education on symptom management.Assists in facilitation of appointments with the primary care provider, palliative care nurse practitioner, pain management provider, specialists, and other members of the health care team as indicated. Maintains a caseload consistent with program guidelinesProvides verbal and written reports as requested.Competencies:To perform the job successfully, an individual should demonstrate the following competencies: Analysis/Problem Assessment Securing relevant information and identifying key issues and relationships from a base of information; relating and comparing data from different sources; identifying cause-effect relationships.Compassion - The responsibility to put a patient's or person's interests first, including the duty not to harm, deliver proper care, and maintain confidentiality. Compliance - Employee has satisfactory completed employers required compliance training. Employee is able to demonstrate an understanding of employers Code of Conduct. Communication - Expressing ideas effectively in individual and group situations (including nonverbal communication); adjusting language or terminology to the characteristics and needs of the audience. Good listening skills.Dependability - Meets commitments, deliverables, deadlines, work independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, and meets attendance/punctuality requirements.Individual Leadership/ Influencing - Using appropriate interpersonal styles and methods to inspire and guide individuals (fellow employees) toward goal achievement; modifying behavior to accommodate tasks, situations, and individuals involved.Innovation - Generating creative solutions to work situations; trying different and novel ways to deal with organizational problems and opportunities.Integrity - Maintaining and promoting social, ethical, and organizational norms is conducting internal and external business activities. Judgment/ Problem Solving - Recognizes problems and responds, systematically gathers information, sorts through complex issues, seeks input from others, addresses root cause of issues, makes timely decisions, can make difficult decisions, uses consensus when possible, and communicates decisions to others. Maximizing Performance - Establishing performance/development goals, coaching performance, providing training, and evaluating performance.Organizational Awareness - Having and using knowledge of systems, situations, procedures, and culture inside the organization to identify potential organizational problems and opportunities; perceiving the impact and the implications of decisions on other components of the organization. Patient Service Orientation - Proactively developing patient/customer relations by making efforts to listen and understand the customer and their needs (both internal and external); anticipating and providing solutions to customer needs; giving high priority to patient/customer satisfaction. Ensures appropriate follow up and is their advocate in determining solutions. The employee uses a variety of communication techniques to effectively express thoughts and ideas and to understand or influence. Planning and Organizing/ Work Management - Establishing a course of action for self to accomplish a specific goal; planning proper assignments of personnel and appropriate allocation of resources.Results Driven & Execution - Accountable for meeting or exceeding individual and/or department goals and objectives. Committed to producing results that will achieve company objectives. Sets priorities and organizes time to meet or exceed goals, follows up, and takes personal responsibility for results whether they are positive or negative.Teamwork/ Collaboration - Working effectively with team/work group or those outside formal line of authority (e.g., peers, senior managers) to accomplish organizational goals; taking actions that respect the needs and contributions of others; contributing to and accepting the consensus; subordinating own objectives to the objectives of the organization or team. Listens to others and values opinions.Work Standards - Setting high goals or standards of performance for self, direct reports, others, and the organization; being dissatisfied with average performance; self-imposing standards of excellence rather than having standards imposed by others. Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Education and/or Experience - Registered Nurse, Bachelor's degree from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience. Preferred experience in Palliative Care/Hospice NursingLanguage Skills - Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints. Relational Skills Must be able to demonstrate empathy, compassion, and caring. Must be comfortable participating in conversation, with the patient, family, caregiver(s), with focus on end of life, death and dying, patient/family fears and anxieties. Must treat patient and family with dignity and respect.Mathematical Skills - Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.Reasoning Ability - Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.Computer Skills - To perform this job successfully, an individual should have knowledge of Athena Database software; Microsoft Spreadsheet software and Microsoft Word Processing software; including Excel.Certificates, Licenses, RegistrationsRegistered NursePhysical DemandsThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.While performing the duties of this Job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance and talk or hear. The employee is frequently required to sit. The employee is occasionally required to stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.Work EnvironmentThe work e

Millennium Physician Group


Fort Myers, FL

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