Field RN; Hospice​/Palliative Care- Houston, TX

Field RN (Hospice/Palliative Care)- Houston, TX at Optum summary:
The Field RN in Hospice/Palliative Care provides comprehensive nursing assessments and care coordination for patients with life-limiting illnesses in their homes, aiming to reduce hospitalizations and improve quality of life. This role involves interdisciplinary collaboration, patient and family education, advanced care planning, and performing clinical procedures such as wound care, phlebotomy, and injections. The RN also documents care, manages case loads, and supports caregiving needs while adhering to regulatory and company standards.
Well Med, part of the Optum family of businesses, is seeking a RN Field Case Manager to join our team in Houston, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.
As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.
At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and erience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country.

Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.
The Care Coach Connect RN/Case Manager coordinates care and provides ongoing nursing assessments of the patient and family needs in coordination with the patient’s plan of care.
The Care Coach Connect RN/Case Manager works closely with the interdisciplinary team members and the Care Coach Connect supervising clinician.

Primary Responsibilities:

• Conducts telephonic and in home patient assessments on established Care Coach Connect patients

• Conducts urgent/acute visits on established Care Coach Connect patients with the goal of keeping the patient out of the hospital in order to receive the best medical care at home

• Provides ongoing assessments of the impact of life-limiting and/or chronic illness(es) on the patient’s physical, functional, psychosocial and environmental needs

• Assess for caregiver burnout and provide community resources when appropriate

• Implement the individualized plan of care and recommend revisions to the plan as necessary

• Ability to perform procedures, to include, but not limited to:
- Wound care and dressing change
- Phlebotomy
- Injections (B12, vaccines)

• Ability to conduct an advance care planning discussion with patient and their family and properly document their wishes in the electronic medical record

• Consults and educates the patient/family and other caregivers regarding the disease process, pain and symptom management, end of life care and processes for dealing with issues of ethical concern

• Initiates appropriate preventive and rehabilitative nursing procedures when appropriate

• Ensure continual assessment of patient and family needs from admission to Care Coach Connect throughout the course of care.

• Provides ongoing evaluation of the patient and family/caregiver response to care and recommends alteration of the plan when necessary

• Attends the interdisciplinary meeting and is a crucial and vocal member of the team

• Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. Decision making is usually based on prior practice or policy, with some interpretation. Applies individual reasoning to the solution of a problem devising or modifying processes and writing procedures

• Conducts telephonic nursing follow up and case management when necessary

• Serves as a resource or consultant for LVN/MA

• Attends educational offerings to keep abreast of chronic medical conditions and complies with licensing…