Primary and Palliative Care Nurse - RN/LPN PRN

Scope of Responsibility

Essential Functions:

• Conducts nursing assessments within scope of practice.
• Makes regular monitoring of patient symptoms, functional status, and disease progression.
• Identifies changes in patient condition and communicates findings to the provider.
• Initiates transition to hospice with guidance and certification of Medical Director.
• Assists with symptom management interventions under provider direction.
• Advocates for patient goals, preferences, and advance care planning decisions.
• Recognizes changes in patient condition and initiates appropriate interventions or referrals.
• Participates in quality improvement initiatives, staff education, and professional development activities.
• Serves as a resource and mentor to nursing staff and support personnel as appropriate.
• Applies principles of infection control and follows guidelines for universal precautions in accordance with accepted professional practices.
• Care Coordination:
• Coordinates care with physicians, nurse practitioners, social workers, specialists, home health agencies, hospice providers, and community resources.
• Aids in transitions of care following hospitalization or emergency department visits.
• Facilitates communication among members of the healthcare team.
• Serves as a support for continuity of care across multiple care settings.
• Principal Care Management (PCM) and Care Management Support:
• Participates in patient outreach and follow-up activities.
• Aids in care plan implementation and updates.
• Serves as a support for medication reconciliation efforts.
• Documents carer coordination and patient communication activities.
• Escalates clinical concerns requiring provider intervention.
• Serves compliance with PCM and other care management program requirements.

Documentation:

• Maintains accurate and timely documentation in the electronic health record (EHR).
• Documents patient encounters, symptom assessments, interventions, and care coordination activities.
• Ensures documentation meets regulatory and organizational standards.

Quality and Compliance:

• Adheres to all state nursing regulations and organizational policies.
• Maintains patient confidentiality in accordance with HIPAA regulations.
• Participates in quality improvement and patient safety initiatives.
• Completes required training and competency assessments.

Physical Demands:

• Talking: Especially where one must frequently convey detailed or important instructions or ideas accurately, loudly, or quickly.
• Motion: Movements frequently and regularly required using the wrists, hands, and/or fingers.
• Hearing: Able to hear average or normal conversations and receive ordinary information.
• Visual: Average, ordinary, visual acuity necessary including close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
• Physical: Will regularly be required to sit, use hands to finger, handle or feel objects, tools, or controls; reach with hands and arms. Must be able to stand, walk, stoop, kneel, crouch, or crawl. Must be able to sit in front of computer monitor for long periods of time. Must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 20 pounds, and occasionally lift and/or move up to 40 pounds.

Health Status:

• There may be exposures to blood, body tissue, and/or fluids, as well as other hazardous waste materials in performance of this job.

Work Environment:

• Healthcare environment: noise level is usually moderate.
• A working environment regularly presents the possibility of exposure to pathogenic organisms, including life-threatening blood borne pathogens and Tuberculosis.
• Use of appropriate personal protective equipment according to Universal Precautions for Infection Control guidelines is required.

Travel Required:

• Must be able to travel to enter in and function in the homes of any patient/caregiver as well as other facilities.
• Must be able to travel to VIA Health Partner locations.

Qualifications

Qualification Requirements:

• A Diploma or associate degree in nursing is required; bachelor’s degree is preferred for RN.
• A current, active, and unrestricted compact (multistate) license as an LPN or RN is required.
• The Nurse Licensure Compact (NLC) allows a registered nurse (RN) and licensed practical/vocational nurse (LPN/LVN) to have one multistate license in a primary state of residency (the home state) and to practice in other compact states (remote states), while subject to each state’s practice laws and discipline.
• Current CPR required.
• Minimum 1-year related experience. Experience in direct care of patients required. Experience may include palliative care, hospice, home health, geriatrics, oncology, chronic disease management, and primary care.
• Computer proficiency is required; electronic health records.

Knowledge, Skills, And Abilities:

• Excellent interpersonal and communication skills (both written and verbal).
• Strong problem solving and critical thinking skills.
• Well organized, self-directed, and able to manage time.
• Flexible, innovative, resourceful, and creative.
• Ability to interact with patients and family members in a varying psychosocial circumstance complicated by the presence of serious or chronic illness.
• Ability to be diplomatic yet assertive.
• Knowledge of nursing principles, practices, and policies, and sound clinical skills.
• Excellent ability to work within a team.
• Excellent ability to coordinate and foster multi-interdisciplinary care.

Reasoning Ability:

• Ability to deal with a variety of variables.
• Able to interpret various instructions.

Mathematics Ability:

• Ability to perform basic math skills, use of decimals to compute ratios and percents, and to draw and interpret graphs.

Language Ability:

• Ability to read a variety of books, journals, magazines, instruction manuals, regulations, interpretive guidelines, and instructions.
• Ability to prepare memos, reports, and essays using proper punctuation, spelling, and grammar.
• Ability to communicate distinctly with appropriate pauses and emphasis, correct pronunciation (or sign equivalent), and variation in word order using present, perfect, and future tenses.