Title:Registered Nurse (RN) Care Coordinator

Department:Home Care & Hospice

FLSA Status:Exempt

Reports To:President & CEO

Summary: Provides care coordination for Chinese patients identified by AAMG, CCHCA, and Dignity Health who are most at-risk for developing a serious illness, both acute and chronic, in advance of their need for palliative and hospice care. Job duties will mostly be performed at the patients’ homes when the RN Care Coordinator makes the first visits to assess the patients’ care needs and develops a comprehensive care plan with oversight from the project steering committee. Subsequent visits will also be done in-person.  

Essential Functions:

⦁  Plan, organize, and direct care coordination for the Chinese patients discharged from Dignity Hospitals, or referred from CCHCA (Chinese Community Health Care Association) and AAMG (All American Medical Group).

⦁  Act as Case Manager/Care Coordinator for designated projects. Prepares care plan, coordinates with project steering committee, and integrates services with existing home care, hospice, and social services teams. 

⦁  Assesses and identifies patient and/or family needs and provides appropriate physical and emotional support in accordance with physician’s orders and plan of care. 

⦁  Develops, evaluates, and revises patient’s individualized plan of care in collaboration with Hospice and Palliative Medicine Physician and Director of Patient Care Services, and other members of the Inter-Disciplinary Group and patient’s primary care physician.

⦁  Evaluates progress towards desired outcomes and updates the patient’s plan of care as appropriate to changing patient and family needs. 

⦁ Coordinates all patient and family services and community resources as needed. 

⦁  Assesses all aspects of the patient’s pain and develops an individualized pain management plan. 

⦁  Anticipates, prevents, and treats undesirable symptoms or secondary symptoms.

⦁  Supports the patient’s unique spiritual and cultural beliefs.

⦁  Maintains the dignity, confidentiality, and privacy of the dying patient.

⦁  Provides holistic, family-centered care to improve the patient’s quality of life. 

⦁  Identifies and addresses signs of actively dying patients.

⦁  Coordinates physical care of the patient by teaching and/or training patients, primary caregivers, volunteers, employed caregivers, and by providing direct care as appropriate. 

⦁  Collaborates and consults with the interdisciplinary group to discuss issues related to patient care.

⦁  Coordinates patient care plan of declining patients with after hours on call staff.

⦁  Coordinates care for patient with staff of SNF and RCFE/Board and Care facilities.

⦁  Supervises performance of Home Health Aides. 

⦁  Participates in in-service training programs for professional staff, as well as quality assurance and performance improvement activities.

⦁  Completes patient-related documentation within 24 hours of the shift worked. 

⦁  Coordinates and manages patient care with awareness of insurance benefits, necessary authorizations, and cost containment.

⦁  Adheres to and complies with state and federal regulations.

Qualifications:

⦁  Must be currently licensed by the CA Board of Registered Nurses.

⦁  Minimum of one year of professional nursing experience in community health or patient-centered care, palliative care, hospice, home health, public health, homecare, acute or sub-acute care. Trained in or is eligible for palliative care certification. 

⦁  Must be able to cope with patient and family emotional stress and be tolerant of individual lifestyles without judgment. 

⦁  Self-directed and able to work with minimal supervision.

⦁  Currently CPR Certified; must pass health screening for TB clearance, physical examination, and background check.

⦁  Must have ability to withstand prolonged or considerable walking, standing, lifting; position, and transfer patients; lift supplies and equipment; reaching, stooping, bending, kneeling, and crouching; and have the visual and hearing acuity to perform required nursing skills. 

⦁  Computer proficiency in Microsoft Office 365, and ability to use electronic health record software.

⦁  Knowledgeable of Medicare regulations.

⦁  Bilingual in English and Cantonese. Mandarin & Taishanese a plus.

⦁  Must be able to travel via public transportation or personal/department vehicle for performance of job duties. If driving, must have and maintain a valid CA driver license, satisfactory driving record, and auto insurance coverage as specified in Self-Help's policy.

Self-Help for the Elderly is an Equal Employment Opportunity/Affirmation Action Employer and we welcome diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, age, national origin, sexual orientation, disability, protected veteran status or any other characteristics protected by law. We participate in E-Verify.

Qualified applicants with criminal history will be considered for employment in accordance with the San Francisco Fair Chance Ordinance.

We may provide reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please call (415) 677-7600 for special assistance.