RNIII Case Manager

Hospice of the East Bay•Pleasant Hill, CA

8d•$61 - $64

About The Position

The RN Case Manager identifies each patient’s and family’s physical, psychosocial, environmental, safety, and developmental needs and individualizes the patient’s plan of care accordingly. Reporting to the Team Manager, the RN coordinates patient and family care, continuously assesses their needs, and implements the plan of care under the direction of the attending physician and Medical Director/Hospice physician, in conjunction with the interdisciplinary team. Hospice nursing services are based on initial and ongoing assessment and are provided in accordance with the interdisciplinary team’s care plan. Hospice of the East Bay follows California RN Case Manager ratios of 12:1. The position provides hospice nursing care across treatment settings, including patients’ homes, skilled nursing facilities, residential care facilities, and board-and-care settings. Care includes pain and symptom management, comfort care, patient and caregiver education, documentation, coordination with the interdisciplinary team and other care providers, and support for patients’ spiritual and cultural beliefs. The role also coordinates transitions and transfers to general inpatient (GIP) and respite levels of care, and supervises Home Health Aide and LVN performance. The schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m.

Requirements

Current California Registered Nurse license.
At least one year of experience working as a professional nurse in an acute clinical setting.
Current CPR certification.
Current California driver’s license and a car in good working condition.
Ability to perform a complete nursing physical assessment, develop a comprehensive care plan, and respond to patient and family needs in home settings, including SNF and RCFE/Board & Care.
Ability to cope with patient and family emotional stress and respect individual lifestyles without judgment.
Ability to establish professional boundaries and maintain cooperative relationships with professionals.
Excellent interpersonal communication and customer service skills, initiative, dependability, and good judgment.
Ability to work collaboratively as part of an interdisciplinary team and independently, and to problem-solve in a crisis.
Must take and pass an annual medication-calculation competency exam with a score of 85% or higher.
Demonstrated clinical competency as observed during a supervisory visit.
Basic computer skills.

Nice To Haves

Prior hospice and/or home-care experience.
Hospice and Palliative Care Nurse Certification.
IV knowledge and expertise.

Responsibilities

Identify and address signs of active dying and transitioning.
Communicate and collaborate with patient care staff, MSW, and SCC.
Assess all aspects of patient pain and develop individualized pain-management plans.
Anticipate, prevent, and treat undesirable symptoms and secondary symptoms; identify and address comfort-care needs.
Support, instruct, and educate patients, families, and caregivers using teach-back; educate and document education of home and facility caregivers with appropriate tools.
Document problems, nursing assessments, goals, care provided, interventions, and patient and family outcomes in a timely manner.
Maintain the dignity, confidentiality, and privacy of dying patients and support their spiritual and cultural beliefs.
Provide holistic, family-centered care across treatment settings to improve quality of life.
Consult and collaborate with the interdisciplinary team and others involved in patient care.
Coordinate and manage patient care while considering insurance benefits, authorizations, and cost containment.
Coordinate care plans with After Hours and Crisis Care staff.
Attend, document, and present appropriate patient-related information at Interdisciplinary Team Meetings using IDT templates.
Update comprehensive assessments and track patient progress toward desired outcomes.
Follow state and federal regulations, accreditation standards, and agency-endorsed evidence-based standards of practice.
Coordinate transfers to GIP and respite levels of care and coordinate care with assisted living and skilled nursing facilities.
Communicate with the Team Manager as appropriate about patient acuity, scheduling, workload, and difficult situations.
Complete required records, reports, and documentation according to agency requirements and timelines.
Follow the agency’s process for effective handoff communication.
Participate in educating new staff members as assigned by the Team Manager.
Supervise the performance of Home Health Aides and LVNs.
Attend appropriate staff in-services and participate in QAPI activities as requested.
Initiate and monitor medication reconciliation processes according to Medicare and accreditation standards.
Respond to email and voicemail communications in a timely manner.