The Care Coach Connect RN coordinates care and provides initial ongoing nursing assessment of the patient and family needs and coordination of the patient's plan of care with interdisciplinary team members and the Care Coach Connect supervising clinician. The CCC Registered Nurse is responsible for performing 90% home visits and 10% telephonic case management. Primary Responsibilities: • 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 Required Qualifications: • 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 clinical experience as a Registered Nurse in a home health, hospice/skilled nursing 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 • Willing to conduct in-home member visits up to 90% of the time • Valid driver's license within the state of work • This position requires Tuberculosis screening as well as proof of immunity to Measles, Mumps, Rubella, Varicella, Tetanus, Diphtheria, and Pertussis through lab confirmation of immunity, documented evidence of vaccination, or a doctor's diagnosis of disease 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 Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.