The registered nurse is a member of the core interdisciplinary group whose primary function is to assess physical, medical, psychosocial, emotional and spiritual needs of the seriously ill patient and family. The registered nurse is designated to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and to work with the interdisciplinary group to implement the plan of care. 

• Provides expert, individualized coordination of care to patients and families.
• Completes initial and on-going comprehensive physical and psychosocial assessment of the patient and family to identify needs and areas for intervention. 
• Ensures appropriate referrals to specialists when indicated and support adherence to treatment plan, including physician visits for evaluation and on-going management. 
• Assists patients in accessing appropriate services and resources in the community to improve their overall health and well-being. 
• Educates patient and family to enhance understanding of disease processes and plan of care, including discussion of treatment options to ensure informed decision making. 
• Provides emotional support and counseling to patients and their families to improve transitions, adjustment to illness and adherence to treatment plan. 
• Evaluates the patient’s physical and emotional recovery after treatment utilizing appropriate resources as needed.
• Empowers patients to take control of their health care by encouraging appropriate goal-setting and discussions about advance care planning/development of advance directives. 
• Builds relationships with other clinicians involved in the patients’ care.
• Attend and participate in internal VITAS Palliative Care’s team meetings.
• Promotes patient-centered approach to care. 
• Partners with healthcare team to manage transitions of care between hospital, primary and specialty care 
• Facilitates proactive discharge planning or follow-up to promote better outcomes, decreased length of stay and reduced readmission rates. 
• Protects patient rights to privacy and safeguard confidentiality when releasing patient information. 
• Utilize a customer service approach in all interactions with VITAS customers.
• Adhere to the practice of confidentiality regarding patients, families, staff and the organization.
• Participate in on-call rotation as needed.

Experience:

• Minimum 2 years of experience in an acute care setting, preferred.
• 1-2 years Case Management experience in a community setting preferred (home health, rehab, hospice, etc.) experience preferred. 
• Knowledge of the interdisciplinary team concept.
• Experience in patient education, planning, and management desired.
• Exceptional communication and customer service skills.
• Ability to communicate tactfully, verbally and in writing with department heads, managers, coworkers and vendors to resolve problems and negotiate resolutions. 
• Working knowledge of computers, internet access, and the ability to navigate within an automated system as well as a variety of software packages such as Outlook, Excel and Word.

Education: 

Certification & Licensure:

• Current and Valid License in the state position is based.
• CPR, BLS/ACLS Certification.
• CHPN certification preferred.
• Reliable transportation, current state driver’s license and automobile insurance.

Physical Requirements:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.

• EOE/AA M/F/D/V