Registered Nurse (RN) Case Manager - Hospice

ATEX Healthcare•McAllen, TX

About The Position

The Registered Nurse Case Manager plans, organizes, and directs home care services, drawing on nursing experience and community health education to meet the needs of individuals and families in their homes and communities. The role ensures staff and other support resources are appropriately used and maintains interdisciplinary teamwork through delegation of duties for Home Health and Hospice. The nurse assesses patients and families, develops and revises plans of care, provides nursing interventions and education, coordinates services, and communicates with physicians and other care partners. When assigned by the Clinical Supervisor, the nurse serves as Case Manager and coordinates care for an assigned caseload. The position also provides clinical direction and supervision to aides and LPN/LVNs and participates in on-call duties.

Requirements

Current, valid nursing license in the state of employment.
One to two years of recent acute care experience in an institutional setting.
Current, valid CPR certification.
Licensed driver with an automobile insured in accordance with state or company requirements and in good working order.
Able to perform the job functions with or without accommodations.
Comply with acceptable professional standards and practice.
Demonstrate good communication and management skills.
Demonstrate autonomy, organization, assertiveness, flexibility, and cooperation.

Nice To Haves

Bachelor’s degree.
One year of Home Health and/or Hospice care experience.

Responsibilities

Complete initial and ongoing OASIS assessments or comprehensive assessments of the effects of terminal disease on patients’ physical, functional, psychosocial, and environmental needs.
Provide complete physical assessments and histories of current and previous illnesses, and regularly reassess nursing needs.
Develop, implement, document, and revise plans of care to support quality and continuity of care as patient status and needs change.
Use assessment data to determine nursing diagnoses and establish goals and therapeutic, preventative, and rehabilitative nursing actions.
Include patients and families in care planning and counsel them regarding nursing and related needs.
Administer medications and treatments as prescribed by physicians.
Educate patients and families about disease processes, self-care, end-of-life care, nutrition, and dietary needs, as applicable.
Prioritize needs with members of the interdisciplinary group or team and provide training to other staff as needed.
Provide health care instructions appropriate to the assessments and plan of care.
Determine the scope and frequency of services based on acuity and patient and family needs.
Identify discharge planning needs and implement discharge plans before the patient’s discharge.
Serve as Case Manager when assigned by the Clinical Supervisor and coordinate care for the assigned caseload.
Prepare clinical notes and update the primary physician when necessary and at least every 60 days.
Communicate patient needs and changes in condition to physicians, obtain or receive physician orders as required, and inform physicians and other personnel of changes and intervention outcomes.
Communicate with community health-related personnel to coordinate the plan of care.
Participate in on-call duties as defined by the on-call policy.
Ensure arrangements are made for equipment and other necessary items and services.
Provide clinical direction to aides and LPN/LVNs to ensure quality and continuity of service.
Instruct, supervise, and evaluate Home Health and/or Hospice aide care every 14 days.
Follow company policies and procedures and perform other duties as assigned.