Our Cause: ONGOING EXCELLENCE Cabrillo Hospice was created to serve; it’s as simple as that. We exist to be more than just health care. We believe that fostering a relationship with each patient and family, which is reflective of their life’s journey, is the key to not only the best care but actively creates the platform for the Cabrillo team to be the most impactful. Creating a culture in an organization that is driven by more than just bottom-line results, we focus on our professionals, structuring a pathway of development for each of them. Simply put, we choose to invest in our most precious resource, the Cabrillo team. Job Title/Position: Registered Nurse Case Manager (work from home and travel position seeing patients in the field)  Travel Area: Chula Vista/La Mesa  Reports To: Team Leader   JOB DESCRIPTION SUMMARY The Registered Nurse Case Manager plans, organizes, and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individual and families within their homes and communities. ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES Patient Care * The Registered Nurse Case Manager completes an initial, comprehensive, and ongoing assessments of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es). * Provides professional nursing care by utilizing all elements of nursing process. * Assesses and evaluates patient’s status by: * Writing and initiating plan of care * Regularly re-evaluating patient and family/caregiver needs * Participating in revising the plan of care as necessary * The Registered Nurse Case Manager uses health assessment data to determine nursing diagnosis. * Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process. * Initiates appropriate preventive and rehabilitative nursing procedures. 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 per assessment and plan. * Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care. * Acts as Case Manager and assumes responsibility to coordinate patient care for assigned caseload. Communication * 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. * Communicates with community health related persons to coordinate the care plan. * 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 group. * The Registered Nurse Case Manager provides and maintains a safe environment for the patient. * Assists the patient and family/caregiver and other team members in providing continuity of care. * Works in cooperation with the family/caregiver and hospice Interdisciplinary Group Members to meet the emotional needs of the patient and family/caregiver. * Attends interdisciplinary group meetings. Additional Duties * 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. * Supervises ancillary personnel and delegates responsibilities when required. * Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and inservice classes. * Fulfills the obligation of requested and/or accepted case assignments. * The Registered Nurse Case Manager actively participates in quality assessment performance improvement teams and activities. POSITION QUALIFICATIONS * Registered nurse with current licensure to practice professional nursing in the state of California. * Graduate of National League for Nursing accredited school of nursing. * Maintains a current CPR certification. * Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order. * Registered nurses shall have a minimum of (a) one (1) year of experience as a professional nurse within the last three (3) years OR (b) have a baccalaureate degree in nursing from a program accredited by the National League for Nursing and a current RN license. Minimum of two years’ experience, at least one of which is in the area of public health, home care, or hospice nursing is preferred. * Self-directed and able to work with minimal supervision. * Management experience not required. Responsible for supervising hospice aides. * Demonstrates excellent observation, problem solving, verbal and written communications, nursing skills per competency checklist. * Shows ability to organize and prioritize workload independently. * Prolonged or considerable walking or standing. Able to lift, position, and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, and/or crouching. Visual acuity and hearing to perform required nursing skills.