RN Case Manager- Facility Team (HPH Hospice)

Chapters Health System•Brooksville, FL

4d•$61,861 - $96,657

About The Position

The RN Case Manager assesses and identifies patient and family needs using 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 while incorporating psychosocial, spiritual, cultural, physical, and biological considerations, and appropriate nursing interventions and follow-up. The RN Case Manager coordinates individualized Plans of Care that reflect evolving patient needs; educates patients, families, caregivers, and health professionals; reports changes in condition; and collaborates with the IDT on hospice referrals and admissions. The position may include facility representation and referral coordination, home visits, and phone support. During emergencies, the employee may be required to report to a company-designated location ahead of schedule and stay overnight as needed to maintain continuity of services.

Requirements

Current RN license in the state where the employee will work.
Minimum of 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 for assessments.
Ability to perform the essential job functions and physical requirements, with or without reasonable accommodation, including lifting patients or equipment, bending, pushing or pulling, and kneeling.
Active BLS for healthcare professionals certification from the American Heart Association or Red Cross.
For employees working at PACE: certification of completion of Alzheimer's Disease and Related Dementias Training through the Florida Department of Elder Affairs.
Ability to see, hear, talk, walk, and use hands to finger, handle, or feel; frequently stand, sit, reach, lift, bend, and balance; occasionally pull, push, stoop or crouch, kneel, and climb stairs.
Consent to drug and/or alcohol testing after a conditional offer and ongoing compliance with the Drug-Free Workplace Policy.
For Florida affiliate services, eligibility verification through the Florida Care Provider Background Screening Clearinghouse after a conditional offer and ongoing eligibility.

Nice To Haves

Hospice or hospital nursing experience.

Responsibilities

Assess and identify patient and family needs using the nursing process.
Coordinate the Plan of Care with the IDT and ensure it is individualized and reflects evolving patient needs.
Provide and manage direct care to patients and families, incorporating psychosocial, spiritual, cultural, physical, and biological components and appropriate nursing interventions and follow-up.
Educate patients, families, caregivers, and other health professionals about disease processes 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; visit frequency is determined by risk score and needs.
Report changes in patient condition to appropriate IDT members or other health professionals.
Participate with the IDT in evaluating hospice referrals and admissions for level-of-care appropriateness, including attending daily IDT collaboration meetings.
Present concise and pertinent oral and written reports to the IDT, respecting and encouraging 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 locations where this is required; help resolve questions or arrange in-person visits when needed or requested.
Use appropriate support, expert 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, address questions and concerns empathetically, provide information to physicians and IDT members, initiate Plans of Care for immediate needs, initiate skilled nursing interventions, obtain physician orders, and complete documentation according to company policy.
Represent the company at assigned facilities and facilitate referrals across service lines; work with referring hospitals, physicians, facilities, patients, families, and the public.
Communicate clinical information promptly using SBAR, discuss potential needs with after-hours staff, and develop relationships with facility case managers and physicians.
During emergencies, report to a company-designated location as required, potentially ahead of scheduled work time and staying overnight to maintain continuity of services.
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 community and professional organizations, performance improvement, quality assessment activities, and company research and educational activities; maintain professional knowledge and skills, improve electronic media skills, and share expertise with coworkers.
Complete competency requirements for the position and perform other duties as assigned.