Palliative Care RN Care Navigator - Maryview Medical Center

Thank you for considering a career at Bon Secours!
S cheduled Weekly Hours:
40
Work Shift:
Days (United States of America)
Primary Function/General Purpose of Position
The Palliative Nurse will reflect a holistic approach to caring for his/her patients with serious or life-threatening illness. The Palliative Nurse will work within the medical team providing specialty palliative care to patients and their families. The individual will support and advise others within the palliative medicine interdisciplinary team. The individual will demonstrate expert nursing direction in the development and delivery of palliative care to patients within Palliative Medicine. The Palliative Nurse will exercise a high degree of clinical autonomy for care management with his/her patients. The Palliative Nurse will contribute to the training and education of others, developing clinical practice across all aspects of palliative care. The Palliative Nurse will be an effective, engaged, and positive team member of Palliative Medicine, supporting its dynamic environment as well as the Bon Secours Medical Group's strategic vision.
Top Daily Duties of RNs
In Collaboration with interdisciplinary care team, conduct initial and ongoing patient assessment, analyze assessment data, create plan of care, implement and evaluate treatment effectiveness
Care coordination, transitions of care, post chronic follow-up, post ED, complex case management for high risk patients, gaps in care
Follow up phone calls when patient misses appointment (cancelation or no show) to help patient clinically understand how we can impact (outpatient clinic)
Call when at least 3 admin attempts have been made for new referrals and still unsuccessful in scheduling (outpatient clinic)
CC inbox- symptom management; triage phone calls throughout the day
Other episodic issues that arise on the daily with patients not currently in the office
Assist patients with Advance Care Planning; scheduling a separate session when appropriate
IDT preparation and report out
II.Employment Qualifications
This position requires an RN degree and a current Commonwealth of Virginia Nursing License.
Baccalaureate degree preferred.
Certified Hospice and Palliative Nurse (CHPN) credential as accredited by the Hospice and Palliative Credentialing Center preferred
Obtain CHPN credential within 2 years of hire
Proficient in Palliative Care Nursing Competencies including but not limited to: clinical judgment, advocacy and ethics, professionalism, collaboration, systems thinking, cultural and spiritual competence, facilitator of learning, communication, evidence-based practice and research utilization.
Proficiency in basic computer skills, including the ability to maneuver within a Microsoft Windows environment.
Complete Honoring Choices ACP Facilitator training within 2 years of hire; maintain Facilitator certification
Obtain POST certification within 2 years of hire
III.Essential Job Functions
Clinical Responsibilities
Assessment: collects data to create a comprehensive hx, including hx of present illness, functional, psychosocial, emotional, patient/family coping skills with advanced illness, cognitive, spiritual, social needs, potential barriers to care and support systems in place.
Able to communicate with providers initiation of needed tests and interpret basic lab results in relationship to patient care.
Able to use nursing dx terminology in caring for patients and setting up nursing intervention in palliative care
Proficient with palliative care assessment tools (i.e. ESAS) and able to incorporate into nursing care planning.
Able to develop components of care plan using nursing dx, management of palliative patient outside of practice and hospital setting (follows patients along the continuum ie. hospice, hospital, etc.), management of common symptoms experienced by palliative patients, and pain, etc. In addition, maintains maintenance of care plans.
Uses evidenced-based interventions when managing the patient using evidenced based clinical protocols when available
Educates the patients and their families about decision making during serious illness and able to address Advance Care Planning with patient and health care surrogate/proxy.
Demonstrates high level of critical thinking.
Able to drive patient discussion in interdisciplinary team rounds
Triages calls for Palliative Medicine office practice and admission into palliative.
Care Coordination:
Provides leadership in the coordination of interdisciplinary health care for integrated delivery of patient services.
Able to prescribe the necessary system and community support measures to maximize the patient's quality of life in the community.
Advocates for the delivery of dignified and human care by the interdisciplinary team.
Builds effective relationships with case managers in the inpatient settings, nurse navigators in the outpatient setting and others involved in care coordination in order to effect/maximize the quality of the patient experience
Able to navigate the various health care settings to follow the patient along the continuum of care
Clinic Responsibilities:
Supports all new patient appointments for nursing assessment, vist education and relationship building. This is usually after the MD is finished with their visit.
Review AVS with patient
Assist patients with Advance Care Planning; scheduling a separate session when appropriate.
Performs clinic nurse responsibilities as needed
Able to order essential clinic supplies and maintain supplies as needed
Efficiently integrate and maximize nursing billing opportunities as relevant. Including by not limited to advance care planning, transitions of care, and care management
IV.Other Job Functions

• As a specialty nurse, engage in the specialty practice team environment as a key team member
• Supports a dynamic practice environment involving travel and schedule flexibility to meet practice needs
• Collaborates effectively in a team environment
• Identifies problems and collaborate/communicate effectively to resolve to further the quality of the practice environment
• Supports and mentor new team members in understanding the role of the specialty nurse
• Understands and responds to performance data as is relevant to the quality of the individual and team practice in patient care delivery
• Supports specialty practice accreditation processes and procedures
• Supports specialty processes and procedures including the development and revision as is pertinent to the specialty nurse
• Participates in relevant health system committees to further strategic priorities such as related to MSSP; value based purchasing and other quality programs

V.Working Conditions
The individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.
Bon Secours is an equal opportunity employer.
Many of our opportunities reward* your hard work with:

• Comprehensive, affordable medical, dental and vision plans
• Prescription drug coverage
• Flexible spending accounts
• Life insurance w/AD&D
• Employer contributions to retirement savings plan when eligible
• Paid time off
• Educational Assistance
• And much more

*Benefits offerings vary according to employment status.Department:
Palliative Care MG - Maryview Medical Center
It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a). Accordingly, all applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health- Youngstown, Ohio or Bon Secours - Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employer, please email If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at