RN- Case Manager (HPH Hospice)

Chapters Health System•Wesley Chapel, FL

9d•$61,861 - $96,657

About The Position

The RN, Case Manager assesses and identifies patient and family needs, uses the nursing process, coordinates the Plan of Care with the Interdisciplinary Team (IDT), and provides clinical, palliative, and supportive care to help patients remain in their home environment as long as possible. The role provides and manages direct patient and family care, develops individualized plans that reflect changing needs, and educates patients, families, caregivers, and health professionals about disease progression, prevention, palliative interventions, caregiving, the dying process, and safety. The Case Manager completes assessments, conducts home visits to evaluate safety and care needs, monitors changes in patient condition, and coordinates appropriate clinical interventions and referrals. The position collaborates regularly with the IDT, physicians, facilities, patients, families, and other professionals, and may supervise care provided by Community Health Workers and Home Health Aides. During emergencies, the employee may need to report to a company-designated location outside their scheduled time and stay overnight as needed to maintain services.

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.
Previous experience working with 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 to perform assessments.
Ability to perform essential job functions and physical requirements, with or without reasonable accommodation, including lifting patients and/or equipment, bending, pushing/pulling, and kneeling.
Active BLS certification for healthcare professionals from the American Heart Association or Red Cross.
Satisfactorily complete competency requirements for the position.

Nice To Haves

Hospice or hospital nursing experience.
For employees working at PACE: certificate of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.

Responsibilities

Assess and identify patient and family needs using the nursing process.
Coordinate the Plan of Care with the Interdisciplinary Team and ensure it reflects the patient's evolving needs.
Provide and manage direct patient and family care, incorporating psychosocial, spiritual, cultural, physical, and biological factors and appropriate nursing interventions and follow-up.
Educate patients, families, caregivers, and health professionals about disease process and decline, prevention, palliative interventions, caregiving, the dying process, and safety practices.
Conduct home visits to assess safety, medication compliance, nutritional compliance, durable medical equipment compliance, and the patient's ability to live safely in the community; visit frequency is based on risk score and needs.
Report changes in patient condition to appropriate IDT members and other health professionals.
Participate with the IDT in evaluating hospice referrals and admissions for level-of-care appropriateness, 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 positive approaches.
Supervise patient care provided by Community Health Workers and Home Health Aides as requested.
Provide telephone reassurance to patients and families at some locations, help address questions, determine when in-person visits are needed, and coordinate visits as appropriate.
Use appropriate support or expert resources 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 compassionately, address questions and concerns, provide information to physicians and IDT members, initiate a Plan of Care for immediate needs, obtain physician orders, and complete documentation per Company policy.
Act as the Company representative at assigned facilities and facilitate referrals to service lines; build relationships with case managers, physicians, and facility contacts.
Provide timely clinical communication using SBAR and discuss potential needs with after-hours staff.
During emergencies, report to a company-designated location as needed, potentially ahead of the scheduled time and overnight, to ensure continuity of services.
Perform other duties as assigned and comply with employee responsibilities, including confidentiality, safety, regulatory compliance, professional development, and quality improvement.