Description
Position at Focus Health Medical Group
Job Title : Palliative Care Registered Nurse ( Monday- Friday; 8AM-5PM)
Location : Linda Vista
Job Type : Full Time
Salary Range : $110,000- $140,000 (Based on experience)
About Us :
At Focus Health, we're reimagining primary care delivery in San Diego through an innovative, patient-centered approach that integrates specialized care directly into the primary care setting. As a growing foundation medical group, we're disrupting traditional healthcare models to create more accessible, comprehensive care for patients with serious illness.
Our embedded palliative care program represents a groundbreaking approach to supporting patients with serious illness, with a particular focus on dementia care and a plan to integrate other service lines in future phases. Our specialized care pod provides comprehensive support across the entire care continuum, primarily in our outpatient clinic setting while maintaining flexibility to support patients wherever they are in their journey. The pod model consists of a physician, nurse practitioner, social worker, RN, and MA.
Job Summary :
The Palliative Care Nurse serves as a clinical expert and care coordinator for patients with dementia or other serious illnesses requiring palliative care. This position plays a vital role in supporting comprehensive, patient-centered care across the continuum of care settings. Working within an interdisciplinary team that includes physicians, advanced practice providers, social workers, and chaplains, the nurse delivers expert palliative nursing care with a specialized focus on patients with serious illness. The role encompasses coordinating care transitions, managing symptoms, facilitating advance care planning, patient / family education, and serving as a resource to healthcare staff across multiple care settings.
Key Responsibilities :
Clinical Care
- Assess, facilitate, and coordinate new and existing patient access to full-scope palliative care services using Epic workflows
- Conduct comprehensive serious illness assessments, including physical symptoms, medication side effects, cognitive status, functional abilities, medication review, and psychosocial / cultural needs
- Collaborate with the palliative care team to implement triage criteria that prioritizes urgent patient needs
- Manage incoming referrals, determine eligibility, assess urgency, and input referrals into appropriate tracking systems
- Maintain an organized patient panel with stratification by acuity level to ensure appropriate resource allocation and follow-up frequency
- Prepare daily census accounting for patient changes and staffing needs
- Coordinate care transitions between inpatient, outpatient, and community settings
- Attend interdisciplinary rounds and contribute meaningfully to patient care discussions
- Develop and implement care plans that support patients in acute, sub-acute, home, telehealth and community settings to prevent unnecessary hospital admissions, including early identification of symptom escalation and appropriate interventions
- Identify families in crisis and follow established protocols to ensure their needs are addressed promptly
Clinical Care and Symptom Management
Provide expert nursing assessment and interventions for symptom management in patients with serious illnessesDocument all care accurately and timely in the electronic medical record according to departmental policiesOversee the management of patients in lower acuity levels of need by performing needs assessments and applying program interventionsApply non-pharmacologic management strategies for disease-related behaviors and provide caregiver education / supportParticipate in advance care planning discussions with elderly patients and familiesComplete documentation of advance directives and POLST formsImplement evidence-based interventions for pain and symptom management specific to older adultsCommunicate palliative care plans to referring providers and unit clinical teams to ensure recommendations are implementedMonitor moderate to distressing symptoms and report to palliative care physicians / APPsFacilitate family meetings to address goals of care and end-of-life planningMaintain regular contact with patients and families via telephone and in-person visits to address evolving needsPatient and Caregiver Support and Education
Serve as a resource to patient care units, outpatient clinics, and care staff regarding palliative careIdentify learning needs of patient care staff and communicate these to program leadershipProvide education to patients and families about palliative care options, advance care planning, and services availableMake referrals to appropriate community-based services based on comprehensive needs assessmentDevelop and deliver educational presentations on palliative care topics to clinic staffIdentify and communicate opportunities for quality improvement to program leadershipCreate and maintain educational resources for patients and familiesQuality Improvement and Program Support
Contribute to maintaining and updating program tools (questionnaires, assessment instruments)Create ad hoc reports for program leaders and team members as neededSet appropriate priorities among competing demandsIdentify barriers to optimal pain and symptom management in patients with serious illnessesCollaborate with team members to develop and implement quality improvement initiativesUtilize available information technology to support day-to-day work operationsMeet weekly with interdisciplinary team to review patient panel and summarize interventionsFollow clinic policies and documentation protocols (documentation and compliance)Qualifications :
Education and Licensure
Bachelor's degree in Nursing requiredCurrent Registered Nurse license in CaliforniaPreferred or willingness to obtain certification in palliative care, dementia or hospice and palliative nursing (CHPN, ACHPN, or GRN)Minimum of 2-5 years clinical nursing experienceExperience in an academic medical center or large community hospital preferredDemonstrated experience with patients with serious illnesses, patient assessments and symptom managementExperience facilitating advance care planning conversationsExperience with Epic electronic health record system preferredKnowledge and Abilities
Expert knowledge of evidence-based palliative care practicesStrong understanding of pain and symptom managementKnowledge of age-related physiological changes and their impact on medication managementExcellent communication skills with ability to discuss sensitive end-of-life issuesAbility to communicate clearly, patiently, professionally, and compassionately via telephone and written communicationsStrong organizational and critical thinking skills with ability to triage multiple competing prioritiesAbility to work independently while collaborating effectively with interdisciplinary teamsDemonstrated skill in care coordination across multiple settingsCultural competency in providing care to diverse patient populationsProficiency with electronic health records, Microsoft Office Suite, and basic computer applicationsAbility to maintain patient confidentiality and adhere to HIPAA regulationsDemonstrated skill in accurately assessing patient / family needs and identifying those requiring urgent interventionDemonstrate a commitment to professional development by staying current with evidence-based palliative care practices emerging research, and clinical guidelines.Actively seeks to integrate new knowledge into patient care workflows to ensure optimal outcomes and quality of life for patients and their familiesWorking Relationships :
Reports to : Medical Director of Palliative CareWorks collaboratively with : Palliative care physicians, APPs, social workers, chaplains, pharmacists, unit-based nursing staff, primary care teams, and care management staffPhysical Requirements :
Ability to perform standard physical demands of clinical nursing roleCapability to spend extended time sitting, standing, and walking between patient areasAbility to communicate clearly in person and by telephoneWhat We Offer :
Comprehensive benefits package including healthcare, retirement plans, and paid time offJoin Our Quest : Ready to make a difference every day? We're calling on heroes like you to revolutionize patient care. Let's make healthcare history together!
Metis Practice Solutions is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, marital status, status as a protected veteran, or status as a qualified individual with disability.