- Bachelor's Degree in Nursing BSN (equivalent clinical experience may substitute for BSN)
- 5 Years Nursing experience
- 3 Years Clinical experience in geriatrics, palliative, end of life or similar clinical experience.
- 2 Years Minimum two (2) years of recent pertinent clinical experience as defined by the CBA
- California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED
- Hospice and Palliative Care Nursing Certification preferred or obtained within 2 years of placement in new role.
- Care coordination
- Communication and coordination
- Implements plan of care and strategies to meet the anticipated clinical, quality, and financial outcomes.
- Job knowledge
- Teamwork
- Clinical expertise in the field of geriatrics, palliative, and end of life care required.
- Demonstrates knowledge and application of evidence based clinical principles, clinical guidelines and practice standards in the care and management of people living with serious advancing illness.
- Is a skilled communicator; demonstrated critical thinking and problem solving skills; educator; and mentor to others.
- Incumbent demonstrates effective time management, prioritization and documentation skills and is proficient with Information Systems and computer programs.
advanced illness management - , CA, United States - Sharp Healthplan
Description
Hours:
Shift Start Time:
9:30 AM
Shift End Time:
8 PM
AWS Hours Requirement:
10/ Hour Shift
Additional Shift Information:
Weekend Requirements:
Every Other
On-Call Required:
No
Hourly Pay Range (Minimum - Midpoint - Maximum):
$ $ $86.180
The stated pay scale reflects the range as defined by the collective bargaining agreement between Sharp HealthCare and Sharp Professional Nurses Network, United Nurses Associations of California/Union of Health Care Professionals, NUHHCE, AFSME, AFL-CIO.
What You Will Do
The Advanced Illness Management Navigator's role is to use the nursing process to determine the specialty needs of people living with serious advancing illness and facilitate the development of a care plan and interventions aligning patient goals, preferences and values with care received.
The AIM Navigator is an expert clinical practitioner, using an evidence-based approach and in collaboration with key stakeholders to ensure safe and effective care and care coordination.
The AIM Navigator partners with care team members to coordinate care, resources, and ensures transitions of care are realistic, safe and attainable.
The AIM Navigator participates in data gathering, analysis, and provides recommendations for improving overall quality of care based on outcomes.
The AIM Navigator serves as an expert resource, educator, and role model in the care and management of those living with serious advancing illness.
Functions as a member of the Interdisciplinary Team coordinating care with various team members.Required Qualifications
Evaluates patient/family response to care in relation to individual wishes and discharge goals.
Re-evaluates for changes in status to ensure that the current plan is still effective.
Documents patients'/families' response to interventions, progress, and any alteration of the plan.
Actively participates in ongoing evaluation of effectiveness AIM interventions in alignment with an HRO.
Communicates and coordinates with the patient/family and other members of the health care team to ensure safe and effective care.
Facilitates goals of care conversations, POLST review and works with healthcare team to align goals of care with care received.
Collaborates with the Interdisciplinary team to support patient/family needs.
Provide education to patient/family on disease progression in order to help increase understanding of patient condition and treatment options.
Facilitates transitions in care to improve patient safety, minimize risks and improve quality of life.
Works collaboratively with other team members and departments to determine best treatment options within payer coverage guidelines.
Ensures appropriate documentation resides in the medical record (per organizational protocol and policy).
Communicates and collaborates with internal and external healthcare team members to coordinate appropriate resources to ensure safe and effective patient/family care is delivered.
Collaborates with the Interdisciplinary team to facilitate their implementation of plans for timely discharge, placement, and/or provision of post-discharge resources and services.
Collaborates with case management on appropriate transitions of care based on needs and patient/family wishes.
Documents patient information in palliative care power form to ensure accurate data collection.
Engages in person centered goals of care discussions using evidence based approach, guiding patient/family towards care choices that align with their goals, preferences, and values.
Designs care planning and transitions of care that focus on a safe, effective plan that allow for patient to be in safest environment with intent of minimizing care transitions after discharge.
Interfaces with healthcare team in educator role, assisting care providers to increase knowledge and competency in the care and management of people living with serious advancing illness.
Works collaboratively with AIM Team members and other stakeholders to ensure standardizations, integration, and desired outcomes.
Provides constructive feedback to peers and manager to facilitate conflict resolution.
Exhibits the 12 Sharp Standards of Behavior in a positive and meaningful way.
Knowledge, Skills, and Abilities