If you receive an offer of employment for this position, it is contingent on the satisfactory completion of a pre-employment background check, immunization review, and drug screen (including THC/Marijuana). CareOregon is a federal contractor and must comply with all federal laws.

Job Title

Registered Nurse – Advanced Illness Care

Department

HCP Advanced Illness

Exemption Status

Non-Exempt

Requisition #

24458

Direct Reports

n/a

Manager Title

Advanced Illness and Palliative Care Manager

Pay & Benefits

Estimated hiring range $109,500 - $133,840/year, 5% bonus target, full benefits.

www.careoregon.org/about-us/careers/benefits

Posting Notes

This role will have a community presence 3+ days per week. Territory will include the south area of the Portland metro (Tigard, Lake Oswego, Oregon City, Milwaukie, etc).

Job Summary

The Advanced Illness Care (AIC) Nurse is focused primarily on a defined panel of high-risk patients. They participate as part of a multidisciplinary team to improve outcomes by enhancing community-based support. The AIC Nurse works with members, their families/caregivers, as well as with members of multidisciplinary teams (MDT) across the continuum of care. These members have advanced illnesses and often have other complex medical/psychosocial/addiction issues. The AIC Nurse provides support and care for members in various settings including: all types of members’ home settings, assisted living residences, shelters, hospitals, emergency departments, skilled nursing facilities, clinics, and specialty settings.

The AIC Nurse will support members by offering real-time communication and coordination of care across all clinical settings, engaging the provider as a core member of the team to optimize symptom management. The AIC Nurse educates, counsels, and supports individuals, assists with longitudinal advanced care planning, and comprehensive transitional care. The AIC Nurse will achieve this with a trauma-aware and trauma-informed approach to address the multiple challenges that many CareOregon members face. This role does not direct or lead the care planning process; rather, it contributes to a multidisciplinary care planning process.

Essential Responsibilities

• Provides direct patient care support in a variety of settings for advanced illness patients utilizing palliative care principles, trauma informed care, motivational interviewing, and case management strategies.

• Drives the medical aspects of the care plan, including optimizing symptom management and coordination of medical and social services as well as addressing social determinants of health.

• Utilizes evidence-based guidelines and best practices related to disease specific assessment and interventions.

• Closely partners with the patient’s providers and other members of the MDT across the continuum to facilitate care that meets the individual’s personal needs, values, and preferences and improves outcomes.

• Uses evidence-based approaches to patient education regarding member’s health status, disease state, red flag symptoms, symptom management, medication management and self-management strategies.

• Communicates and coordinates with patient’s providers across the continuum of care to facilitate care that meets their personal needs, values, preferences to ensure care is coordinated and consistent with patient’s goals of care.

• Demonstrates a person-centered approach in working with members by respecting their self-determination and autonomy and exploring their ambivalence by utilizing Motivational Interviewing principles.

• Engages patient and family in advance care planning which includes discussions about goals of care and answering general questions about POLST forms and Advanced Healthcare Directives. Assists patient with documentation if requested.

• Plans, participates and/or facilitates care conferences during which advanced illness patient needs are discussed and evaluated and plans of care are developed and/or updated.

• Participates in IDG meetings as required.

• Collaborates with members of the healthcare team, CareOregon benefit specialists, vendors, and social services to enhance patient satisfaction, to conserve time and resources, and identify barriers.

• Assists clinical teams with management of transitions of care when patients are moving from one setting to another, including (but not limited to) primary residence to hospital or skilled nursing facility and back. Assist with placement if needed.

• Assists in mentoring newly hired staff; may provide coaching and training.

• Provides timely and effective documentation including data collection.

• Actively participates in the development and implementation of the AIC program.

• Identifies and addresses organizational, cultural, and other barriers to best practice strategies.

• Serve as an ambassador for CareOregon and Housecall Providers at all times.

  Organizational Responsibilities

• Perform work in alignment with the organization’s mission, vision and values.

• Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.

• Strive to meet annual business goals in support of the organization’s strategic goals.

• Adhere to the organization’s policies, procedures and other relevant compliance needs.

• Perform other duties as needed.

  Experience and/or Education

  Required

• Current unencumbered license as a registered nurse in the State of Oregon

• Minimum 2 years’ experience working as an RN in one or more the following areas: Home Health, Hospice, Palliative Care, or Community Health, Behavioral Health/Chemical Dependency, and Primary Care

• CPR certification at hire or within 6 months in position

• Valid driver’s license, acceptable driving record, and automobile liability coverage or access to an insured vehicle

  Preferred

• Bachelor of Nursing degree

• Experience working with a diverse community of individuals whose health has been impacted by social determinants, trauma, and marginalization

• Experience utilizing motivational interviewing techniques, and trauma informed interdisciplinary approach to care

  Knowledge, Skills and Abilities Required

  Knowledge

• Knowledge of impact of generational poverty and other social determinants of health on clients’ ability to develop and follow self-care goals to improve health outcomes

• Familiar and comfortable with a person-centered approach to communication, education, and care planning

• Comfortable supporting members at the end of their life; including facilitating, evaluating, and coaching advanced care planning conversations performed by AIC team or other CO programs

• Knowledge of current evidence regarding palliative interventions, and best practice and can disseminate knowledge to others

• Knowledge of community resources to support a complex, vulnerable population

• Familiarity with electronic health record applications; comfortable learning new systems, if needed

  Skills and Abilities

• Ability to be sympathetic to a member, family or caregivers needs, and be able to engage people in various states of pain, trauma, and tragedy

• Ability to exercise sound clinical judgment, independent analysis, critical thinking skills and knowledge of medical and behavioral health conditions when identifying clients’ multidisciplinary needs, developing health goals, and communicating with providers

• Able to work independently and make decisions appropriate to the situation in a complex and rapidly changing environment

• Able to clearly and simply talk about AIC support and recognize the importance of health literacy

• Makes referrals to established CareOregon and community programs as deemed appropriate

• Acts as a role model to advanced illness and palliative care teams for professional behavior, appropriate work ethic and appropriate boundaries

• Excellent communication skills including verbal and written communication in the form of presentations, meetings, emails, reports, networking, and conversation

• Skilled in having advanced care planning conversations is strongly preferred

• Maintains professional relationships with provider community and internal and external customers while identifying opportunities for improvement

• Advanced computer application skills including Microsoft office and internet browsers/applications

• Ability to adhere to organizational standards, policies, and procedures

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions

• Ability to accept direction and feedback, as well as tolerate and manage stress

• Ability to see, read, hear, speak clearly, and perform repetitive finger and wrist movement for at least 6 hours/day

• Ability to pinch small objects for at least 3-6 hours/day

• Ability to stand, walk, sit, bend, push, pull, crouch, crawl, reach, and climb stairs for at least 1-3 hours/day

• Ability to operate a motor vehicle

  Working Conditions

  Work Environment(s): ☒ Indoor/Office ☒ Community ☐ Facilities/Security ☒ Outdoor Exposure

  Member/Patient Facing: ☐ No ☒ Telephonic ☒ In Person

  Hazards: May include, but not limited to, physical, ergonomic, and biological hazards.

  Equipment: General office equipment and/or mobile technology

  Travel: Requires travel outside of the workplace at least weekly; the employee’s personal vehicle may be used. Driving infractions will be monitored in accordance with organizational policy.

  Location: Employees assigned to see members and patients in Columbia or Tillamook counties are required to live within 15 miles of their county assignment.

  Schedule: This position may occasionally require more than 8 hours per day.

  Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.

  Veterans are strongly encouraged to apply.

  We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.

  Visa sponsorship is not available at this time.