RN, Case Manager (HPH Hospice)
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 participants remain in their home environment as long as possible. The role provides and manages direct care, develops and updates individualized plans of care, educates patients and caregivers, reports changes in condition, and participates in evaluating hospice referrals and admissions for appropriate levels of care. The position includes home visits to assess patient needs and home safety, and may involve facility-based coordination, referral support, and regular collaboration with physicians and other IDT members. The RN may be required to report to a company-designated location during emergencies, including working ahead of a scheduled time or staying overnight to maintain continuity of 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 using an EMR/EHR system.
- Valid driver’s license and automobile insurance consistent 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 essential job functions and physical requirements, with or without reasonable accommodation.
- Active BLS for healthcare professionals certification 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 IDT and ensure it reflects the patient's evolving needs.
- Provide and manage direct care, including psychosocial, spiritual, cultural, physical, and biological considerations, with appropriate nursing interventions and follow-up.
- Educate patients, families, caregivers, and 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 and other health professionals.
- Participate with the IDT in evaluating hospice referrals and admissions for appropriate levels of care, and attend daily IDT collaboration meetings.
- Present concise oral and written reports to the IDT and encourage input from all disciplines.
- Communicate accurately and completely with physicians, staff, patients, families, and supervisors, including timely clinical communication using SBAR.
- Supervise care provided by Community Health Workers and Home Health Aides as requested.
- Provide reassurance and assistance to patients and families by phone; identify when an in-person visit is needed and coordinate it.
- Use appropriate support resources to address 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, initiate nursing interventions and Plans of Care, obtain physician orders, and complete documentation according to Company policy.
- Represent the Company at assigned facilities, facilitate referrals to service lines, and develop relationships with case managers, physicians, and facility contacts.
- Discuss potential needs with after-hours staff.
- During emergencies, report to a designated location as required to ensure continuity of services, potentially ahead of schedule or overnight.
- Perform other duties as assigned and fulfill general employee responsibilities, including compliance, confidentiality, professional development, and participation in quality improvement activities.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
