Providence Health & Services PMG at Home Nurse in Portland, Oregon
Providence is calling a PMG at Home Nurse - Pmg At Home (1.0 FTE, Days). This position will be traveling between Newberg, Sherwood, Tigard, and Wilsonville. Shift schedule is 8am to 5pm M-F. Urgent Home visits for prevention of ER admit. Ability to spend time with your patients and get to know them. Combination of acute visits with long term care management.
Apply today! Applicants that meet qualifications will receive a text message with some additional questions from our Modern Hire system.
We are seeking a PMG at Home Nurse - Pmg At Home that will provide case management as well as targeted urgent care assessment and related skilled nursing interventions for medically fragile, at-risk patients and their families/caregivers in the home/community setting with the goal of promoting self-management. The PMG at Home Nurse coordinates patient care activities with other members of the health care team in a collegial relationship to promote patient-centered care in order to effectively identify needs and coordinate access to appropriate care and services as part of an effort to improve or maintain the patients functional status and independence. This position also processes triage calls from existing patients and caregivers, addressing clinical issues and forwarding information to team members as indicated.
In this position you will have the following responsibilities:
Use a systemic process and clinical skills to assess, plan, implement and evaluate an individual plan of care for a patient that spans the continuum of care. The plan of are is developed in conjunction with the Primary Care Provider, the patient and the patient’s family or caregiver(s)
Use principles of utilization management in the decision-making process to assure both quality and cost-effectiveness
Demonstrate the ability to utilize regional population risk stratification information and processes to identify appropriate members for enrollment into case management for complex longitudinal care in collaboration with clinicians and other members of the PMH health care team
Nursing Assessment, Screening and Triage
Complete assessments for fragile, at-risk patients and gathers essential information needed for plan of care
Update assessments in collaboration with the patient, family and/or caregiver, identifying changes in patient conditions and progress towards desired patient outcomes
Prioritize urgent patient/family/caregiver needs utilizing screening tools from relevant sources
Perform hands on nursing care as needed based on patient diagnosis and acuity
Triage calls from existing patients/families/caregivers, addressing clinical issues and forwarding information to health care team members as needed
Incorporate medication review and management into all assessments, integrating pharmacy as needed
Evaluate patient/family/caregiver psychosocial, spiritual and physical needs. Communicates needs to appropriate health care team members, as needed
Provide coordination of care
Prioritize findings from member assessments, identifying patient’s needs and potential issues and/or barriers to care
Engage patients to define and set patient centered goals as part of the plan of care and appropriate level of self-management, and interventions
Develop and document a patient-centered care plan that addresses patient-centered goals that are specific, attainable and measurable in collaboration with patients and family members
Document ongoing follow up and monitoring of effectiveness of the interventions and reinforce the treatment plan
Advocate and provide care coordination and management services for patients with identified needs
Act as a liaison with other members of the PCMH team
Inform the providers, members of the health care team and other parties as indicated of changes in the patient’s conditions and needs
Manage a nursing caseload that includes patients requiring a broad spectrum of care, who reside in a variety of environments and in a wide geographical area by practicing good organizational and time management skills
Collaborate with other agencies as needed, including Home Health and Hospice
Teach, supervise and counsel patients and caregivers on patient care in accordance with the patient and family wishes, beliefs, communication styles and values
Participate as preceptor in the orientation of new staff and/or students as assigned by supervisor
Develop and distribute health literate education, tools, and materials for patient care
Target reduction in unnecessary readmissions or ED visits, improvement in patient experience and health outcomes by appropriate management of urgent clinical issues
Monitor and reassess the plan of care to ensure that quality, quantity and goal achievement are appropriate and cost effective
Contribute to ongoing process improvement including related procedures, policies, and patient support and documentation tools
PMG at Home Nursing Team Functions
Rotate schedule through weekends and holidays as assigned by supervisor.
Perform procedures and treatments according to accepted organizational and department policies and standards
Maintain patient clinical records according to accepted organizational and department policies and standards
Other duties as assigned
Required qualifications for this position includes:
Current, unencumbered state of Oregon RN license
American Heart Association Basic Life Support for Health Care Provider completion required within one (1) month of hire
A valid driver's license
Driving record consistent with GOP Safe Driving Policy 330 Incident Point Matrix at time of hire
Two (2) years of Clinical medical-surgical, acute care or long-term care experience that includes:
One (1) year community-based/ambulatory care
One (1) year in care of the frail elderly
Preferred qualifications for this position includes:
Bachelor's Degree in Nursing
Current recognition by a national professional organization in case management
Case Management Society of America (CSMA) CCM credential.
American Case Management Association (ACMA) ACM credential
American Nurses Credentialing Center (ANCC) RN-BC
Nine (9) months of Home health, hospice, palliative care, managed care, -OR- skilled nursing facility background
One (1) year of Care management of diverse patient populations
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,
"Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Home Health Nursing
Req ID: 314409