RN Case ManagerField

Why Work for Us?

Partners In Care (PIC) is an independent 501(c)(3) nonprofit organization and the largest, oldest provider of home health, palliative care, and hospice services in Central Oregon. Serving Deschutes, Crook, and Jefferson counties, our dedicated team of over 200 employees and 200 volunteers delivers compassionate, patient-centered care across a 10,000-square-mile area. Additionally, Hospice House in Bend, Oregon, is a specialty hospital for inpatient hospice care, creating an oasis of tranquility and comfort for patients and their families.

We prioritize excellence, empathy, and collaboration, fostering a culture of kindness, respect, and learning while valuing diversity and the well-being of our employees, volunteers, patients, and families.

Full Time (hourly, non-exempt) 40 hours per week.

Hours:

8:00 AM to 5:00 PM (8-hour Shift)-Monday-Friday. Work outside of these hours may be required.

Location:

This role involves local/regional travel throughout Central Oregon via personal vehicle during the workday, including visits to patients' homes and facilities.

The Registered Nurse plans, coordinates, implements, and evaluates home health and hospice services, with an emphasis on community health education and nursing experience. The professional nurse builds from the resources of the organization & community to provide services to meet the needs of individuals and families within their homes. The Registered Nurse is responsible for cost-efficient and effective patient care with quality outcomes.

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

Complete an initial comprehensive (if HH includes OASIS) and accurate assessment of the patient and family to determine home health needs. Provide a complete physical assessment and history of previous illness (es) and use the health assessment data to determine appropriate diagnosis and need for other disciplines and resources.

Develop an individualized care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Include the patient and the family in the planning process. Make necessary revisions to the care plan as patient status and needs change. Complete and update the ongoing assessments and care plan as patient’s status changes.

Initiate appropriate preventive and rehabilitative nursing procedures and treatments and/or end of life comfort procedure. Administer medications and treatments as prescribed by the physician.

Ensure that arrangements for equipment and other necessary items and services are available.

Provide health care instructions and education to the patient and or family as appropriate per assessment plan and patients’ caregivers’ ability to learn. Adapt teaching styles to meet patient’s needs and family’s needs.

Identify discharge-planning needs as part of the initial care plan development and implement prior to discharge of the patient.

Develop, monitor, and update the HCA plan of care as necessary including completion of HCA supervisory visits no later than every 14 days. The HCA plan of care is complete, accurate, and updated every certification or as patient needs change.

Update the primary physician when necessary and at least every sixty days.

Communicate with the physician regarding the patient’s needs, reports, and changes in the patient’s condition; obtain/receive physician’s orders as required.

Communicate with all members of the healthcare team to promote coordinated, efficient care and document coordination of care with all involved with patient care.

Initial assessments are complete, accurate, and submitted within 48-72 hours of admit. Additionally, ongoing clinical documentation is complete, accurate, documented, and submitted within 24 hours of patient visit.

Participate in weeknight and weekend on-call duties as defined by the on-call policy.

Adhere to the PIC mission and values. Support the organization.

Graduate of an accredited school of nursing with an unencumbered licensure to practice professional…