Hospice RN Case Manager

Summary:  Provides nursing care case management, emotional support and education to terminally ill patients and their families. Oversees certified nurse’s aides and the overall care plan for each patient. Responsible for managing the medical, equipment and pharmaceutical needs of the patient. Acts as the liaison between patient and physician and nurse practitioner. Demonstrates clinical expertise in nursing assessment, nursing diagnosis, and advanced proficiency in technical skills necessary for developing, providing, and coordinating care to patients.

Qualifications: 

Education Requirements:  Graduate of an accredited Diploma, associate's degree or Baccalaureate School of Nursing. 

Licensure:  Must have current licensure by the Georgia State Board of Nursing and a valid Driver’s License.

Experience Requirements:

• Two (2) to three (3) years hospice experience strongly preferred
• Minimum one-year experience in critical care, medical-surgical nursing, Hospice, Oncology or community health nursing. Hospice case management experience preferred.

Job Knowledge/Skills: 

• Knowledge of the physical, social and emotional needs of the elderly, disabled and terminally ill.
  • Knowledge of Medicare, Medicaid and other funding source regulations as applied to hospice care services.
  • Demonstrate knowledge and competence in advanced practice nursing skills, including the nursing process and collaborating with interdisciplinary team.
  • Skill in communications in order that information can be exchanged effectively with persons at various educational and attitudinal levels.
  • Knowledge of supervision and management in order to effectively relate and manage the care provided by volunteers and other hospice staff.
  • Must be willing to assist with hospice admissions and on-call coverage as needed.

Responsibilities:

Patient Care Skills/Job Duties      

• Provides nursing services as required per skills competency checklist.                               
• Assesses patients for admission to the Hospice Program.  Admits patients for care based on skilled need and payor source eligibility requirements.                       
• Assesses, coordinates and manages the need for additional services to enhance patients’ care.                          
• Makes referrals to other disciplines on behalf of the patient.                          
• Evaluates the patient’s response to care as evidenced by visit note documentation.                                
• Provides education to patient & family regarding disease process, self-care techniques and prevention strategies as evidenced by visit note documentation.                              
• Clinical record documentation demonstrates compliance with physician orders for care provided and frequency of visits made.                           
• Obtains physician’s orders for care and services provided per policy.                                  
• Complies with company’s policies and procedures.                             
• Documentation reflects Home Health Aide supervisory visits done a minimum of every 14 days.                          
• Documentation demonstrates compliance with Medicare, Medicaid and other regulatory requirements.                                  

Documentation/Communication  

• All Clinical documentation is complete and accurate and submitted to office per policy and communication guidelines.                       
• Develops and revises plan of care and/or discharge plan in conjunction with patient, family, physician, facility and care team to meet the patient’s physical, emotional, psychosocial and spiritual needs.                                
• Documentation reflects notification of physician when patients’ status changes and revision to the plan of care as appropriate.                                   
• Prepare an IDT report biweekly to the patient’s attending physician.                       
• Documentation of visits reflects the patients’ response to care and assessment of psychosocial needs throughout the course of care in accordance to the plan of care.                              
• Documentation reflects complete assessment/reassessment of patient and includes goals of care and evidence of discharge planning.                                 
• Documentation reflects patient/family teaching                        
• Documentation reflects communication with Hospice Medical Director weekly after RN visits if changes in patient condition.                             

Management & Supervision                     

• Responsible for overseeing and managing other disciplines involved in the care of patient e.g. certified aids and LPNs.                                 
• Responsible for liaising with all Skilled Nursing Facilities and Assisted Living Facilities ensuring that all required information, care-plan updates and reports are in the patient’s chart at the facilities.                                
• Responsible for ensuring and maintaining Flow sheets and LCDs on admission and recertification of all patients.                                 
• Effectively communicates with team/office staff regarding changes in client status, scheduling changes, patient problems, etc.                               

Infection Control     

• Demonstrates knowledge of infection control standards and techniques as per policy and procedures and consistently practices these techniques.                               

Company Standards          

• Contributes to the attainment of the Hospice Program financial and operational objectives by providing and coordinating cost effective and competent patient care.                                 
• Supports the Hospice philosophy, mission statement, policies & practices and quality values.                                   
• Complies with Hospice dress code policy.                                 
• Reports to work and patient homes promptly as scheduled and remains accessible to the Clinical Manager and/or Executive Director during the entire scheduled workday.                        
• Demonstrates flexibility and willingness to cooperate while working with others or in place of others as necessary.  Easily accepts changes in assignments to accommodate the needs of the care team, patient and family.                        
• Acts as a representative of Weinstein Hospice in the community.                             
• Actively participates in interdisciplinary conferences to coordinate care, problem-solve, and exchange views and information.                        
• Maintains patient and staff privacy and confidentiality at all times according to established procedures.                          
• Knowledgeable of the Human Resources’ personnel policies and procedures as evidenced by staying within the limits and guidelines of the policies.                               

Professional  and Personal Growth         

• Meets requirements for mandatory educational programs and meetings as documented on the Documentation of Orientation and Training and Education form.                       
• CHPN certified preferable.                        
• Attend in-services/updates regarding hospice issues.                         

Transportation: Must have valid automobile insurance coverage and reliable transportation.

ENVIRONMENTAL AND WORKING CONDITIONS: Extensive traveling and working in patients’ homes in various conditions and environments. Highest risk is in terms of personal safety regarding on-road travel.

PHYSICAL AND MENTAL EFFORT: The work involves driving, walking, bending as well as work at a desk. Ability to lift up to 50 lbs. and to move patients. Requires working under some stressful conditions. Identifying patient needs, quick decision making and resource acquisition.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the staff member for this job. Duties, responsibilities and activities may change at any time with or without notice.