Registered Nurse (RN) Hospice Case Manager

Lehigh Valley Health Network•Allentown, PA

2d•Onsite

About The Position

This role is responsible for coordinating and directing the delivery of care for an assigned caseload of patients receiving services in the home setting. The Hospice Case Manager works collaboratively with an interdisciplinary care team to determine the appropriate level of care and skilled need for services based on Conditions of Participation. The position involves initiating, reviewing, evaluating, and revising the plan of care in conjunction with the physician and team to achieve patient goals and quality metrics. Key duties include performing initial and ongoing assessments, providing skilled treatments and interventions, and educating patients and caregivers on end-of-life issues, palliative care, advance directives, pain management, and symptom control.

Requirements

Specialized Diploma NLN approved/accredited nursing program
1 year recent experience providing direct care in a healthcare setting
Knowledge of patient education techniques and principles
Ability to take initiative and function independently without direct supervision
Ability to actively participate as a member of a care team
Exhibit excellent time management and organizational skills
Ability to manage a caseload of patients as per agency standards
Ability to travel to patient care assignments
Knowledge of Conditions of Participation
Knowledge of and skill in completing regulatory data set collection with a high level of accuracy
Highly skilled in verbal and nonverbal communication
Ability to facilitate difficult and complex communication related to goals of care
BLS - Basic Life Support AHA - American Heart Association Within 30 Days
RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire
DL - Driver's License_PA - State of Pennsylvania Upon Hire or DL - Driver's License_NJ - State of New Jersey Upon Hire

Nice To Haves

Associate’s Degree Nursing or Bachelor’s Degree Nursing
1 year experience as a home health or hospice Registered Nurse
Knowledge and ability to navigate multiple computer applications and EMR platforms.
AMB-BC- Ambulatory Care Nursing-Board Certified - American Nurses Credentialing Center within 3 Years or CHPN - Certified Hospice and Palliative Nurse - Hospice and Palliative Nurses Association within 3 Years

Responsibilities

Coordinates and directs the delivery of care for an assigned caseload of patients receiving services in the home setting in collaboration with the interdisciplinary care team.
Initiates, reviews, evaluates, and revises the established plan of care in collaboration with the physician and interdisciplinary team for appropriate care plan progression aimed at achieving patient goals, quality metrics, and level of care transition.
Works in collaboration with other network entities to ensure appropriate delivery of patient care and care progression.
Completes data collection as per CMS regulation with a high level of accuracy that reflects quality outcomes measures and appropriate financial reimbursement for services.
Formulates an individualized plan of care according to physician orders that incorporates the analysis of assessment data and current scientific findings.
Collaborates with the physician.
Determines the appropriate level of care for the patient as well as skilled need for services ordered based on Conditions of Participation.
Relays significant changes in patient status to the physician and other members of the interdisciplinary care team in a time period consistent with patient needs.
Delivers patient care based on the medical plan of treatment established by the physician and protocols using a patient family centered approach.
Provides educational opportunities for patients, families, and clinical staff focusing on end-of-life issues, palliative care, advance directives, chronic disease management, pain management, symptom control, home care, hospice, and discharge planning.
Promotes patient/caregiver autonomy.
Evaluates effectiveness of teaching and modifies education based on patient needs and goals.