RN Case Manager- Facility Team (HPH Hospice)

Chapters Health System•Brooksville, FL

9d•$61,861 - $96,657

About The Position

The RN Case Manager is responsible for assessing and identifying patient and family needs, using the nursing process, coordinating the Plan of Care with the Interdisciplinary Team (IDT), and providing clinical, palliative, and supportive care to help patients remain in their home environment as long as possible. The role works with patients and families, IDT members, physicians, facilities, and other health professionals to coordinate services and respond to evolving patient needs. The RN Case Manager provides and manages direct care, supports individualized care planning, educates patients, families, caregivers, and health professionals, and reports changes in patient condition. Duties may include home visits and assessments, facility representation and referral coordination, documentation in the EMR, and communication with after-hours staff. During emergencies, the RN may be required to report to a company-designated location outside the usual schedule and may need to stay overnight.

Requirements

Current RN license in the state where the employee will work.
At least one year of nursing experience; hospice or hospital experience is preferred.
For employees working at PACE, completion certification for Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.
Previous experience using an EMR/EHR system.
Valid driver's license and automobile insurance in accordance with Company policy.
Reliable transportation to meet the visit schedule.
Ability to use equipment with visual and auditory mechanisms.
Ability to communicate effectively in English, verbally and in writing.
Ability to visit participants in their homes for assessments.
Ability to perform the essential functions and physical requirements of the job, with or without reasonable accommodation, including lifting patients and/or equipment, bending, pushing or pulling, and kneeling.
Active BLS certification for healthcare professionals from the American Heart Association or Red Cross.
Ability to see, hear, talk, walk, and use hands to finger, handle, or feel.
Ability to stand, sit, reach, lift, bend, and balance frequently, and to pull, push, stoop or crouch, kneel, and climb stairs occasionally.

Nice To Haves

Hospice or hospital nursing experience.

Responsibilities

Assess and identify patient and family needs using the nursing process, and provide clinical, palliative, and supportive care.
Provide and manage direct patient and family care as part of the Interdisciplinary Team, including appropriate nursing interventions and follow-up.
Coordinate the Plan of Care and ensure it reflects the patient's evolving needs.
Educate patients, families, caregivers, and other health professionals about disease progression, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct home visits to assess home safety, medication and nutritional compliance, durable medical equipment compliance, and the patient's ability to live safely in the community.
Report changes in a patient's condition to appropriate IDT members or other health professionals.
Participate with the IDT in evaluating hospice referrals and admissions for appropriate level of care, and attend daily IDT collaboration meetings.
Present concise, pertinent oral and written reports to the IDT and encourage input from all disciplines.
Communicate accurately and completely with physicians, staff, patients, families, and supervisors, using timely clinical communication such as SBAR.
Supervise care provided by Community Health Workers and Home Health Aides when requested.
Provide telephone reassurance to patients and families, help resolve questions, and arrange in-person visits when needed or requested.
Use appropriate support resources or personnel to resolve complex situations.
Document patient and family contacts in the EMR and communicate with the IDT.
Complete initial and semi-annual assessments for Company services.
Explain services to patients and families, address questions and concerns, and present services empathetically and compassionately.
Provide information to physicians and IDT members, initiate a Plan of Care for immediate needs, obtain physician orders, and complete documentation according to Company policy.
Represent the Company at assigned facilities and facilitate referrals to service lines while working with hospitals, physicians, facilities, patients, families, and the public.
Discuss potential needs with after-hours staff and develop strong relationships with facility case managers and physicians.
During emergencies, report to a company-designated location as required, potentially ahead of the scheduled time and staying overnight to maintain continuity of services.
Perform other duties as assigned and meet the competency requirements for the position.