Registered Nurse Case Manager

Job Summary The Registered Nurse Care Manager is responsible for managing and coordinating the plan of care for hospice patients in their place of residence and to coordinate care with the Interdisciplinary Team, patients, families, referring agency/facility, and/or caregivers. The RN administers nursing care for patients utilizing all aspects of the medical plan and nursing standards of care. Directs and guides patient/family education and the activities of other personnel while maintaining standards of professional nursing. Must possess the ability to assess data reflective of the patient’s status and interpret the information to formulate a plan of care based on the patient’s age‑specific needs. Must be able to provide the care needed as described in the department’s policies and procedures. This position plays a critical role in supporting Augusta Health’s mission and advancing departmental goals through measurable performance indicators and service excellence. This position contributes to a collaborative, patient‑centered environment and helps drive outcomes aligned with organizational priorities. Essential Job Duties Medications Completes 5 Rights with 100% compliance. Knowledge of medications used. Knowledge and use of high‑risk medications. Ability to perform calculations for mixtures/solutions. Reconciles patient medications and changes in medications with physician/provider. Evaluation - Evaluate patient outcome Implements/develops/documents the plan of care to ensure quality and continuity of care and recommend revisions to the plan, as necessary. Documentation reflects nursing interventions, patient responses, as well as follow through with patient outcomes. Consults with and educates the patient and family regarding disease process, self‑care techniques, end‑of‑life care, nutrition, and dietary needs. Prioritize any needs with the members of the IDT. Provide training to other staff as needed. Determines scope and frequency of services needed based on acuity and patient/family needs. Assess the ability of the caregiver to meet the patient’s immediate needs upon admission and throughout care. Prepares clinical and progress notes that demonstrate progress toward established goals. Ensure continuity of quality patient care delivered with appropriate documentation. Evaluation of age specific instruction/teaching is demonstrated and documented through monitoring of the learning process, seeking feedback from patients and family, and return demonstration if appropriate. Responsible for improving patient outcomes and comfort at end‑of‑life. Responsible for fiscal utilization of services/supplies per patient. Assess/Plan - Assess and develop individualized needs and plan of care Initial and ongoing comprehensive assessments are complete and appropriate for patients age, special care needs, patient’s knowledge level, and psychosocial, emotional, physical, functional, environmental, and spiritual needs. Applies specific criteria for admission and re‑certification to hospice care to establish appropriate levels of care and the patient’s eligibility. Reassessment is timely and performed as patient condition warrants. Informs physician/provider and other team members of changes in the patient’s needs and outcomes of intervention, while evaluating patient and family response to care. All documentation is submitted in a timely manner and per documentation policy. Communicates patient information as necessary to the interdisciplinary team and other nurses as required. Appropriate referrals are made with evidence of follow‑up documentation in the medical record. Personal Growth Assumes responsibility for own personal education and developmental needs. Assesses personal learning needs and initiates methods to meet the identified needs through formal or informal education. Displays positive attitude and flexibility toward work unit. Cooperates with interdisciplinary team members and other units to meet the needs of the patient. No complaints from patients/family, other units, physicians or staff. Attends 50% of staff meetings. Attends in‑services as required or requested by clinical manager. Maintains clinical competency. Abides by AH service standards. Participate in quality improvement processes Participates in staff satisfaction projects. Assist Clinical Manager on quality improvement projects when requested. Knowledge of department QAPI projects. Provides suggestions for cost containment. Assist unit in ACHC preparedness by maintaining environment and practicing within established standards. Knowledge of ACHC standards as it relates to everyday work practices. Awareness of patient satisfaction goals to meet individual patient/family needs on a daily basis. Leadership - Demonstrates effective skills to be a leader within the department Provides clinical directions to the Hospice Aide and LPN to ensure quality and continuity of service provided. Completes Hospice Aide and LPN supervisory visits as required. Able to function as a team leader ensuring optimal patient care while supervising the work of other supportive nursing staff. Demonstrates ability and knowledge to be a resource and mentor for other staff. Minimizes absences and reports to work in a dependable manner. Communicates effectively with physicians/providers utilizing SBAR approach. Able to function calmly and promptly while demonstrating appropriate knowledge and skill in emergency situations. Promotes the Hospice’s philosophy. Maintains responsible attitude towards management and cost containment. Serves on organizational committees as requested by Clinical Manager. Provides mentoring and orients new nurses, students and aides as assigned. Implement Implement clinical and technical aspects of care in accordance with established standards, policies, and practice guidelines. Anticipate patients’ potential complications and need for appropriate preventive measures. Demonstrates strong clinical skills in technical aspects of care, pain management, systems assessment, and patient satisfaction. Demonstrates efficiency in documentation by documenting at least 75% at the point of care. Demonstrates proficiency in starting IVs and phlebotomy and follows policies and procedures. Maintains patient safety. Maintains patient confidentiality. Provides patient education appropriate to age and knowledge level of patient. Demonstrates proficiency in computer applications necessary to perform the job. Coordinates care through use of interdisciplinary services as needed. Maintains equipment as assigned. Reports damages/problems to manager, quality controls are done per department policy when indicated. Personal Safety Follows department’s infection control policies. Consistently uses Personal Protective Equipment including eye protection when appropriate. Maintains organization and safety in the physical environment of care. Demonstrates knowledge of proper body mechanics. Disposes of sharps, medications, and infectious waste appropriately per policy. Maintains calm and safe approach with those patients that display violent or aggressive behavior. Practices safe driving. Patient Safety Demonstrates knowledge of patient two unique identifiers. Utilizes SBAR approach to patient hand off communication. Follows policy and procedure in the administration of medication and medication reconciliation. Applies concepts of infection control and standard precautions in coordinating and performing patient care activities to prevent contamination and transmission of disease. Abides by policies/procedures for Isolation. Consistently follows CDC guidelines for hand hygiene. Knowledgeable of their role in department emergency preparedness plan. Documents appropriately by not using an abbreviation from standard “..Do Not Use Abbreviation List..”. Implements fall preventions. Involve family/caregiver in fall prevention measures. Labels all specimens appropriately in home. Required Qualifications Education: Nursing Diploma and/s or Associate Degree in Nursing. Licensure/Certification: Current and valid Registered Nurse license in the Commonwealth of Virginia or from a state that is part of a compact agreement with Virginia. CPR-Basic Life Support Healthcare Provider Certification (BLS-HCP). Experience: Minimum of one (1) year of recent RN experience. Driver's License: Yes. To drive an Augusta Health Vehicle, must also be 21 years old and Motor Vehicle Record (MVR) must be approved by Risk Management. Eligibility to work in the United States and meet Virginia state employment requirements. Preferred Qualifications Education: BSN/MSN. Licensure/Certification: CHPN Certification. Experience: Hospice experience preferred. Prior experience in a hospital, healthcare system, or related service‑oriented environment. Familiarity with Augusta Health’s systems, workflows, or organizational culture is a plus. Competencies, Knowledge, Skills and Abilities IV therapy, wound care, general medical/surgical assessment skills. Clinical competence in all aspects of hospice care. Completion of annual education requirements and department competencies. Demonstrates good leadership and communication skills. Demonstrates job related computer competence as seen in patient documentation and information retrieval. Documentation is submitted timely. Practices within scope of Nurse Practice Act. Familiar with current Standards of Nursing Practice. Familiar with CMS hospice regulations and ACHC standards applicable to daily work practices. Ability to work a flexible schedule. Pay Transparency Statement The pay range reflects the current compensation range for this position at the time of posting. Individual offers are determined based on directly related experience, skills, education, internal equity, and other job‑related factors. Not all candidates will qualify for the upper end of the posted range. Equal Opportunity Statement Augusta Health recruits, hires, and promotes qualified candidates for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran or military discharge status, and family medical or genetic information. We are committed to fostering a diverse and inclusive workplace in accordance with federal and Virginia state employment laws. #J-18808-Ljbffr