The RN, Case Manager is responsible for assessing and identifying patient/family needs, utilizing the nursing process, coordinating the Plan of Care with the Interdisciplinary Team (IDT), and providing clinical, palliative and supportive care to the patient/family unit in order to keep the participant in their home environment as long as possible. This role involves managing direct care to patients and families as part of the Interdisciplinary Team (IDT), incorporating psychosocial, spiritual, cultural, physical and biological components, and appropriate nursing intervention and follow-up. The Case Manager coordinates the Plan of Care, ensuring it accurately reflects the patient’s evolving needs. They educate patients, families, caregivers, and other health professionals about disease processes, decline, prevention, palliative interventions, caregiving, the dying process, and safety practices. Home visits are conducted to assess home safety, medication compliance, nutritional compliance, and Durable Medical Equipment (DME) compliance to determine the ability to live safely in the community. The RN reports changes in patient condition to appropriate members of the IDT or other health professionals and participates with the IDT to evaluate hospice referrals/admissions for level of care appropriateness. They attend daily IDT collaboration meetings and present concise and pertinent oral and written reports, respecting and encouraging input from all disciplines. Accurate and complete communication is maintained with physicians, staff members, patients, families, and supervisors, utilizing positive approaches. The RN supervises patient care provided by Community Health Workers and Home Health Aides as requested. In times of emergencies such as hurricanes, the RN, Case Manager may be required to report to a company-designated location to ensure continuity of services, which may include reporting before their scheduled date/time and staying overnight.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
Job Type
Full-time
Career Level
Mid Level