Supportive Care Management - Registered Nurse

The SCM Registered Nurse assists patients, with high-risk or chronic conditions, in determining and achieving their best level of health and quality of life wherever they call home. These patients may be experiencing a significant change in their disease progression or chronic health condition resulting in a referral to Unity’s SCM program to determine if the patient can benefit from an added layer of nursing support. The length of time the SCM RN would assess and monitor a patient would be determined by the patient’s goals. The SCM RN, as part of the interdisciplinary team, will assist the patient/family in deciding if and when hospice care may be appropriate.

Key Job Duties

1. Meet with perspective patients to share the SCM program.
2. Complete RN portion of admission process
3. Collaborate with Unity SW and NP to create patient centered plan of care including patient centered goals
4. Provide in person and telephonic case management
5. Manage medications and treatments
6. Assess risk of decompensation and hospitalizations.
7. Manage symptoms
8. Educate patients and caregivers regarding specific diseases.
9. Coordinate care among all specialists once the goals of care are defined.
10. Develop after hours emergency plan with patient and caregiver
11. Coordinate care delivery with multidisciplinary team members and others.
12. Delegate tasks and other duties appropriately providing adequate supervision.
13. Adhere to established policies and procedures and safe practices.
14. Employ strategies to promote health and safe practice through teaching and health promotion.
15. Collect comprehensive data pertinent to the patient's health and situation.
16. Identify expected outcomes for a plan individualized for a patient or a situation.

General

1. Comply with all applicable local, state and federal laws and regulations as well as policies and procedures of Unity
2. Satisfy mandatory training requirements regarding local, state and federal regulations and/or Unity’s policies and procedures
3. Consistently and concisely document activity according to department protocols and standards
4. Promote and maintain confidentiality
5. Maintain personal and professional boundaries
6. Perform other job-related duties as assigned
7. Maintain regular and reliable attendance

Customer Service

Strives for superior service to the extent we exceed our customers' expectations/needs

1. Recognize the needs and expectations of internal and external customers
2. Respond to identified needs and expectations, producing positive customer outcomes
3. Treat customers (internal/external) with respect and dignity

Team

Demonstrate support for the key organizational values relative to people

1. Treat other members of the team with respect and integrity
2. Demonstrate partnership which works towards common team goals
3. Demonstrate flexibility and/or willingness to adjust work schedule to assure adequate staff levels
4. Anticipate and respond to needs
5. Apply effective interpersonal communication skills
6. Respond to people and issues with knowledge/facts
7. Recognize contributions of team members and provide support/feedback

Continuous Improvement

Supports organizations efforts focused on continuous improvement

1. Identify issues as they relate to the process improvement and customer satisfaction
2. Maintain ongoing involvement with system improvement
3. Follow through with system improvement changes

Physical and Environmental Requirements

Essential Physical/Environmental/Technical Skills:

Employees must have the ability to; operate computers, telephones, and other office equipment, communicate both verbally and in writing, sit for prolonged periods of time as required by position, walk, bend and lift up to 10 pounds on occasion, organize and prioritize tasks.

Exposure to Hazards:

In the course of duties there may be a risk of “occupational exposure”. An occupational exposure defined by OSHA is “reasonable anticipated skin, eye, mucous membrane, nonimpact skin, or parental contact with blood and other potentially infectious material that may result from the performance of an employee’s duties.” This may also include other potentially hazardous materials.

Personal Protective Equipment (PPE):

PPE is one measure available to all employees to help reduce the risk of contracting blood borne illnesses and other diseases. It is the employee’s duty to assess the need for PPE’s and the appropriate kind to be used. Furthermore, it is the employee’s responsibility to wear and use the PPE that has been made available.

Accountabilities for Mission

Support and maintain the mission, vision and values of Unity.

HIPAA Access

Protected Health Information (PHI) may only be accessed as needed to complete assigned job duties.

Education

1. Register Nurse, Bachelor’s degree in nursing preferred.

Knowledge, Skills and Abilities

1. Two years nursing experience
2. Experience in care/disease management, health coaching, utilization review, and/or discharge planning
3. Demonstrated ability of adhering to clinical and regulatory standards, program development, managing department protocols and processes and managing patient flow required.