RN Palliative (CA - Oroville/Butte County)

Registered Nurse (Rn) Palliative Community Care Coordinator (Pccc)

The registered nurse (rn) palliative community care coordinator (pccc) serves as a cornerstone of compassionate, patient-centered care within a multidisciplinary population health team for the adobe provider group california (apg ca). This role supports patients with complex medical, behavioral, and social needs, bridging the gap between clinical treatment and community-based support.

The rn provides comprehensive care coordination, clinical assessment, education, and palliative care services, ensuring each patient receives holistic support tailored to their unique needs. By combining clinical expertise with empathetic engagement, the rn helps improve quality of life, health literacy, and care outcomes while reducing unnecessary hospitalizations and healthcare costs.

This position is hybrid, requiring both remote work and travel to patient homes and community settings in oroville, throughout butte county, and surrounding areas.

Duties & Responsibilities

Clinical Care & Patient Assessment

• Conduct comprehensive in-home and telehealth nursing assessments, evaluating physical, psychosocial, and environmental factors that impact health outcomes.
• Meet members in a variety of settings that may include, but not limited to houses, group homes, skilled nursing facilities, etc.
• Perform vital signs monitoring, review medical history, complete medication reconciliation, and identify potential safety or adherence risks.
• Provide clinical nursing interventions as appropriate, including wound care, medication administration, and patient teaching.
• Identify and respond to changes in patient condition, collaborating with physicians and care teams to implement timely interventions.
• Quality delivery of clinical assessment skills and practices.
• Deliver palliative and supportive care focused on comfort, dignity, and quality of life, addressing pain, symptom management, and emotional well-being.
• Participate in transitions of care, helping patients navigate from hospital to home or between care settings safely and effectively.
• Must be comfortable having end-of-life conversations, planning, and assisting with the completion of advance directives.

Care Coordination & Case Management

• Develop, implement, and revise individualized care plans that integrate medical, behavioral, and social determinants of health.
• Serve as the clinical liaison between patients, families, providers, and community agencies to ensure seamless, coordinated care.
• Partner with physicians, advanced practice providers, social workers, and therapists to conduct interdisciplinary case reviews and panel management.
• Conduct follow-up calls, telehealth visits, and home visits to monitor progress and reinforce care plans.
• Facilitate access to resources such as hospice referrals, behavioral health support, transportation, and food security services.

Education, Empowerment, & Support

• Provide disease-specific education to patients and caregivers on conditions such as diabetes, copd, hypertension, heart failure, and dementia.
• Educate on symptom recognition, medication safety, nutrition, exercise, and advance care planning.
• Empower patients to participate actively in self-management and care decisions.
• Offer emotional support, coping strategies, and grief counseling for patients and families facing chronic illness or end-of-life challenges.
• Must be able to speak on the sensitive nature of death and dying.
• Ability to help coordinate care plans for the patient and family.
• Advocate for patient autonomy, dignity, and informed choice in all aspects of care.

Community Outreach & Resource Navigation

• Conduct home safety evaluations and recommend adaptive equipment or environmental modifications to enhance independence and reduce risk.
• Engage in community outreach to connect patients with social, financial, and medical resources that support well-being.
• Collaborate with outreach teams to locate and re-engage patients who are non-compliant or difficult to reach.
• Participate in community events, health fairs, and patient education programs to promote awareness of available services.

Clinical Documentation & Compliance

• Accurately document all assessments, interventions, communications, and outcomes in the electronic health record (ehr) in accordance with policy and regulatory requirements.
• Maintain strict adherence to hipaa regulations, ensuring confidentiality and data integrity.
• Track and report quality metrics, patient outcomes, and care coordination activities to support program improvement.

Professional Collaboration & Development

• Mentor and provide guidance to lvns, medical assistants, and community health staff as appropriate.
• Participate in bi-weekly care team huddles, clinical rounds, and performance improvement initiatives.
• Engage in continuing education and maintaining clinical competencies relevant to community-based nursing and palliative care.
• Adapt to evolving technology platforms, documentation systems, and clinical protocols.
• Other duties as assigned.

Skills & Qualifications

• Two (2+) years of clinical nursing experience.
• One (1+) year in community health, home health, ambulatory care, population health, or palliative care, or hospice care strongly preferred.
• Strong understanding of chronic disease management, transitions of care, and social determinants of health.
• Excellent communication, interpersonal, and patient advocacy skills.
• Ability to work independently and exercise sound clinical judgment in non-traditional care environments.
• Proficiency with electronic health record (ehr) systems and microsoft office suite.
• Knowledge of hipaa and regulatory requirements for patient privacy and safety.
• Bilingual (english/spanish) preferred.
• Must be able to travel up to 40% within assigned geography. (yuba city, sutter county, and surrounding areas).
• Reliable transportation, valid driver's license, and proof of auto insurance required.

Education, Licenses, & Certifications

• Current and unrestricted registered nurse (rn) license in california.
• bachelor of science in nursing (bsn) preferred.
• cpr/bls certification (aha for healthcare providers).
• iv/blood draw certification through bvnpt regulations.
• annual tb testing.
• unrestricted driver's license.
• proof of current insurance.

Benefits & Total Rewards

• Insurance medical, dental, vision, and life
• 401k plan 3% match
• employee assistance program
• tuition reimbursement
• continued education support
• mileage reimbursement (if applicable)
• referral bonuses
• 9 paid holidays
• 15 days of paid time off
• paid volunteer hours

Character & Competencies

• courage to have the courage to do the right thing at the right time.
• ownership to take ownership of every issue you touch.
• respect to respect yourself, co-workers, and for those whom you care.
• excellence to be excellent in all that you do.
• diversity - demonstrates knowledge of eeo policy; shows respect and sensitivity for cultural differences; educates others on the value of diversity; promotes a harassment-free environment; builds a diverse workforce.
• ethics - treats people with respect; keeps commitments; inspires the trust of others; works with integrity and ethics; upholds organizational values.
• adaptability - adapts to changes in the work environment; manages competing demands; changes approach or method to best fit the situation; able to deal with frequent change, delays, or unexpected events.
• customer service - manages difficult or emotional customer situations; responds promptly to customer needs; solicits customer feedback to improve service; responds to requests for service and assistance; meets commitments.
• interpersonal skills - focuses on solving conflict, not blaming; maintains confidentiality; listens to others without interrupting; keeps emotions under control; remains open to others' ideas and tries new things.
• judgement - displays willingness to make decisions; exhibits sound and accurate judgment; supports

Adobe Care and Wellness LLC