We are seeking a Continuous Care Nurse to service our patients throughout the Columbia area. The role of the Continuous Care Nurse er position is a critical part of the patient's care team, to provide in-home intensive, short-term, bedside clinical care to manage uncontrolled symptoms. The Continuous Care Hospice Nurse collaborates closely with the interdisciplinary hospice team to stabilize symptoms and ensure comfort, dignity, and safety. Provide quality healthcare in adherence to all applicable laws, regulations, and policies within the scope of practice.
The Nurse Case Manager will have a full patient load against all patients in the region based upon priority
Nurse Case Manager's perform care in homes in their designated service area.
You must have reliable transportation as travel is required daily. This is a full time, salary-based working position
- Track Schedule 7 on 7 off 12/hr shifts PM shift
The following service area(s) are currently available: What Are We Looking For? Your Health is currently looking for a Registered Nurse to join our growing primary care family. A successful Nurse Case Manager will be able to perform these essential duties and responsibilities. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.
The following is a list of essential functions, which may be subject to change at any time and without
notice. Management may assign new duties, reassign existing duties, and/or eliminate function(s).
Area of Responsibility: - Facilitate receiving all medical records from the patient's primary provider and specialists.
- Review medical records.
- Complete consents with patients.
- Enroll patients in Care Management, if they meet eligibility criteria.
- Initiate a Care Management Plan of Care, if the patient is eligible.
- Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
- Complete AWV's to be reviewed by the provider.
- Complete cognitive impairment screenings.
- Complete Social Determinants of Health (SDoH) assessments and/or screenings.
- Complete ACP's to be reviewed with the patient by the provider.
- Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
- Evaluate for RPM devices, resources, or tools that may improve the patient's quality of life.
- Communicate and coordinate care.
- Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments.
- Provide post-discharge education.
- Evaluate for adaptive equipment and DME.
- Evaluate for safe environment.
- Evaluation of acute condition(s) or follow-up from previous visit.
- Appropriately and accurately document and log Care Management activities. Work in conjunction with care team to keep the patients Care Management care plans up to date.
Qualifications: - Must be a licensed nurse. Registered nurse preferred. License must be in good standing with appropriate board/issuer.
- A minimum of three (3) years clinical experience preferred.
- Experience in community settings preferred.
- Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
- Strong written and verbal skills.
- Basic computer knowledge.
- Ability to manage and demonstrate effective leadership skills.
- Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
- Ability to foster a cooperative work environment.
- Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
- Must be able to work flexible hours and travel between offices, facilities, etc. Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order
