RN, Case Manager (HPH Hospice)

Chapters Health•Lecanto, FL

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 care to patients and families as part of the IDT, incorporating psychosocial, spiritual, cultural, physical, and biological considerations, with appropriate nursing interventions and follow-up. The Case Manager completes initial and semi-annual assessments, initiates skilled nursing interventions, obtains physician orders, and documents care in accordance with company policy. The position educates patients, families, caregivers, and other health professionals about disease progression, prevention, palliative interventions, caregiving, the dying process, and safety practices. Visit frequency depends on risk score and needs. Home visits assess safety, medication and nutritional compliance, durable medical equipment compliance, and ability to live safely in the community. The RN communicates patient changes and clinical information to physicians and other IDT members, participates in daily IDT collaboration meetings and hospice referral/admission evaluations, and presents concise oral and written reports. The position may represent the company at assigned facilities and coordinate referrals across service lines. It may also supervise care provided by Community Health Workers and Home Health Aides when requested. During emergencies, the RN may be required to report to a company-designated location ahead of schedule and stay overnight to maintain continuity of services.

Requirements

Current Registered Nurse (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: certificate of completion of 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 to conduct assessments.
Ability to perform the essential job functions and physical requirements, including lifting patients and/or equipment, bending, pushing, pulling, and kneeling, with or without reasonable accommodation.
Active Basic Life Support (BLS) certification for healthcare professionals from the American Heart Association or Red Cross.
Satisfactorily complete the competency requirements for the position.
Consent to drug and/or alcohol testing after a conditional offer of employment and ongoing compliance with the Drug-Free Workplace Policy.
For employees performing services for Florida affiliates: pass eligibility verification through the Florida Care Provider Background Screening Clearinghouse after a conditional offer and maintain ongoing eligibility.

Nice To Haves

Hospice or hospital nursing experience.

Responsibilities

Assess and identify patient and family needs using the nursing process.
Coordinate an individualized Plan of Care with the Interdisciplinary Team (IDT), reflecting the patient’s evolving needs.
Provide and manage direct patient and family care, including appropriate nursing interventions and follow-up.
Complete initial and semi-annual assessments for company services.
Provide reassurance and support to patients and families by phone; resolve questions or arrange in-person visits as needed.
Initiate skilled nursing interventions to prevent complications, alleviate symptoms, and maximize physical and emotional comfort.
Obtain physician orders and complete documentation according to company policy.
Educate patients, families, caregivers, and other health professionals about disease process and decline, 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 ability to live safely in the community.
Report changes in patient condition and communicate clinical information to IDT members, physicians, staff, patients, families, and supervisors in a timely and accurate manner, including use of SBAR.
Participate with the IDT in evaluating hospice referrals and admissions for level-of-care appropriateness, and attend daily IDT collaboration meetings.
Present concise and pertinent oral and written reports to the IDT and encourage input from all disciplines.
Act as the company representative at assigned facilities and facilitate referrals to all service lines; work with referring hospitals, physicians, facilities, patients, families, and the public.
Develop relationships with facility case managers, physicians, and other contacts; discuss potential needs with after-hours staff.
Supervise patient care provided by Community Health Workers and Home Health Aides when requested.
During emergencies, report to a company-designated location as required, which may involve reporting early and staying overnight to ensure continuity of services.
Perform other duties as assigned.
Represent the company professionally; comply with applicable regulations and company policies; maintain confidentiality; use resources responsibly; and observe health, safety, and security practices.
Participate in performance improvement, quality assessment, professional development, community and professional organizations, and company research and educational activities as appropriate.