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Enhanced Care Nurse-LTC
HOS00 CMS RAVEN GRANT
Oakland and various locations
UPMC Community Provider Services (CPS) manages those patient-based services that happen outside the hospital and, most often, after a hospital stay. CPS operates in more than 50 physical locations and provides services throughout a 10-county area. These services enhance UPMC''s mission of excellence in patient care and extend its reach throughout the care continuum. Services include home care services, UPMC Senior Communities, ancillary services, and rehabilitation services.
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The Enhanced Care Nurse (ECN) for the RAVEN project supports and serves the nursing facility clinical needs under the direction of the Lead Certified Registered Nurse Practitioner (CRNP). The ECN is responsible for assisting with coordination of RAVEN interventions, communication tools, and assessing and treating residents with acute change in condition or palliative needs. The ECN must demonstrate the knowledge and skills necessary to provide care that is relevant to residents under their care as well as apply principles of growth and development over the life span. They also must possess the ability to assess and interpret resident data needed to identify each resident''s requirements relative to his or her age specific needs.
This position wil work daylight hours with occasional on-call hours.
This position is 100% grant funded through a cooperative agreement. This positions will be based out of Pittsburgh, PA, Hillsdale, PA, Greensburg, PA.
- Responsible for implementation of a negotiated plan of care that includes mutually established goals with resident/family.
- Supervises and delegates resident care activities on the unit to ensure efficient and appropriate services and team documentation as appropriate.
- Coordinates multidisciplinary resident care staff activities as appropriate.
- Demonstrated awareness of the impact of his/her behavior on the efficient functioning of the department/facility.
- Serve as a face for the RAVEN CMS grant, assisting with question, communication and collaboration with stakeholders.
- Perform daily medical review looking for quality of care concerns, readmissions, acute changes in conditions and ways to resolve these issues.
- Apply clinical knowledge to assist in determining if patient needs a medical intervention (acute change in condition or palliative needs) and based on criteria makes appropriate level of care changes (ie. observation to inpatient, inpatient to observation).
- Utilizes nursing process in managing the care of residents including assessment, interdisciplinary planning, implementation, evaluation of resident care, teaching and discharge planning.
- Provides basic psychosocial support and counseling.
- Reports and records all changes observed in condition or behavior of residents.
- Collaborates with multidisciplinary team and offers and documents freedom of choice when arranging RAVEN services.
- Educate patients and multidisciplinary team regarding RAVEN communication tools, palliative care and other Care Management issues.
- Responds to emergent situations and initiates appropriate actions.
- Provides resident/family education.
- Strictly adheres to all policies and practices relative to resident care and hospital related information.
- Documents in the medical record according to established procedures.
- Perform work in a timely and productive manner.
- Establishes appropriate and effective communication strategies.
- Seeks out appropriate nursing, physician, or other health care team intervention as appropriate.
- Attends health team conferences.
- Contributes to the universal unit activities, including but not limited to responding to call lights and telephone, passing meal trays and resident transports.
- Begins to develop interdisciplinary relationships with members of the health care team.
- Constructively receives feedback and direction.
- Takes action to improve knowledge, skills and performance based on feedback or on self-identified development needs.
- Obtain consent to appeal on behalf of the resident regarding situations that need mitigation.
- Coordinate and facilitate patient progression throughout the continuum of care.
- Promote resident safety.
- 5 years of clinical experience as a Registered Nurse required
- BSN or related Bachelors Degree preferred
- Previous case management experience preferred
- Experience in long term care preferred
- Use of electronic health record preferred
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