Home Hospice RN Case Manager - Greater Milwaukee South Counties

Advocate Health and Hospitals Corporation•Milwaukee, WI

About The Position

The Home Hospice RN Case Manager identifies and coordinates patient and family care to support terminally ill patients and their families in hospice settings. The Case Manager assesses needs and determines the frequency of patient and family contacts, with contact at least every 15 days. Using teaching, assessment, and intervention skills, the Case Manager provides end-of-life comfort care and works to maximize quality of life. The role includes educating patients and families about disease processes and trajectories, disease management, hospice philosophy, and signs and symptoms of decline and end of life. The Case Manager updates the primary physician as indicated and in accordance with agency, accreditation, state, and federal requirements. The Case Manager continuously reviews each caseload patient’s care, service utilization, and hospice level-of-care eligibility; makes referrals as appropriate; administers prescribed medications and treatments; and leads the patient- and family-specific interdisciplinary care group (IDG). In collaboration with the IDG, the Case Manager develops, revises, and implements each patient’s plan of care, coordinates services, and arranges or recommends equipment, medical supplies, and other needed services. The role includes ongoing assessment of patient responses, adjusting interventions and follow-up, communicating changes and problems to physicians and the care team, and entering physician or APN verbal orders in the electronic health record. The Case Manager completes and maintains required electronic health record documentation, supervises and performs Home Health Aide and licensed practical nurse supervisory visits, and instructs paraprofessional staff in accordance with applicable standards and regulations. The position also facilitates discharge planning and uses interagency, system, and community resources to support continuity of care. In Wisconsin, the Case Manager may conduct OASIS assessments for Palliative Care patients and hospice initial and comprehensive assessments, establish and update plans of care, and ensure applicable skilled nursing and homebound criteria are met. The role includes preventive and rehabilitative nursing procedures, mentoring new staff when requested, and providing age-appropriate care based on knowledge of growth and development across the lifespan. The position is full-time, 40 hours per week, with a regular Monday–Friday schedule of 8:00 a.m.–4:30 p.m. and a 30-minute lunch. There are no evening, overnight, or weekend requirements; holidays and an on-call rotation are required. On-call duties may include PRN visits during an eight-hour shift. The role requires a valid driver’s license and involves home-based patient care, physical patient handling, and frequent exposure to mechanical, electrical, chemical, and biological hazards.

Requirements

Current Registered Nurse license issued by the state in which the team member practices.
Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association; must be obtained upon hire unless the department leader determines it is not required.
Valid driver’s license issued by the Division of Motor Vehicles.
Completion of an accredited or approved Nursing program.
Typically 1–2 years of nursing experience, including experience in home health, hospice, medical/surgical, long-term care, emergency care/ICU, oncology, or similar related experience.
Competence in deformity prevention, normal range of motion, body mechanics, body alignment, fundamental principles of human behavior, and the effects of stress on individuals and groups.
Strong awareness and perception skills to assess patient needs and concerns and recognize changes in health condition.
Excellent communication and interpersonal skills.
Excellent decision-making and critical-thinking skills, including the ability to work independently and make sound judgments.
Excellent prioritization and organizational skills.
Ability to demonstrate knowledge and skills necessary to provide age-appropriate care and assess and interpret information relevant to patients’ age-specific needs.
Ability to lift up to 50 pounds from floor to waist and up to 20 pounds overhead; carry up to 40 pounds a reasonable distance; and push or pull with 30 pounds of force.
Ability to perform a sliding transfer of 150 pounds with a second person present.
Ability to work safely with people of various sizes and weights and with diverse and complex medical conditions and physical limitations.
Physical agility and stamina to work in confined spaces and perform bending, kneeling, squatting, and occasional overhead reaching for extended periods.
Functional speech, vision, hearing, and touch, including fine-hand manipulation skills.
Ability to wear protective clothing and equipment as needed and operate equipment necessary to perform the job.

Responsibilities

Identify and coordinate care for terminally ill patients and their families in hospice settings, with patient and family contact at least every 15 days.
Assess patient and family needs and provide teaching, assessment, and interventions to support comfort and quality of life at end of life.
Educate patients and families about disease processes and trajectories, disease management, hospice philosophy, and signs and symptoms of decline and end of life.
Update the primary physician as indicated and in accordance with agency, accreditation, state, and federal requirements.
Continuously review each caseload patient’s care, service utilization, and eligibility for the appropriate hospice level of care.
Make referrals to other team members as appropriate and administer medications and treatments prescribed by the physician.
Lead the interdisciplinary care group for each patient and family on the caseload.
Collaborate with the interdisciplinary team to develop, revise, and implement patient plans of care and coordinate services.
Arrange or recommend equipment, medical supplies, and other necessary items and services.
Enter, complete, and update electronic health record documentation according to applicable standards, policies, and regulations.
Assess patient responses to treatments, medications, and teaching; adjust interventions and follow-up as needed; and update plans of care with supporting documentation.
Communicate patient problems and changes in condition to physicians, supervisors, and other interdisciplinary team members.
Enter verbal orders from physicians or APNs into the electronic health record.
Supervise and perform Home Health Aide and licensed practical nurse supervisory visits, and instruct paraprofessional staff as required.
Facilitate discharge planning and use interagency, system, and community resources to support continuity of care after discharge.
In Wisconsin, may conduct OASIS assessments for Palliative Care patients and hospice initial and comprehensive assessments, establish and update plans of care, and ensure applicable skilled nursing and homebound criteria are met.
Initiate appropriate preventive and rehabilitative nursing procedures.
Use proper body mechanics, assistive devices, and safety techniques when positioning, repositioning, and transporting patients.
Orient and mentor new staff as requested.
Provide care appropriate to patients’ ages and assessed age-specific needs.
Participate in the holiday and on-call rotation, including PRN visits during an eight-hour shift.