Hospice RN Nurse Case Manager

Job Description

Job Description

We are seeking Registered Nurse to service our patients throughout the [LOCATION] area. The role of the Nurse Case Manager position is a critical part of the patient’s care team. The nurse will visit patients and facilitate with appropriate provider. The Nurse Case Manager will be required to travel to patients’ homes, long-term care facilities, etc. to evaluate patients and initiate telemedicine visits. Provide quality healthcare in adherence to all applicable laws, regulations, and policies within the scope of practice.

Nurse Case Manager's perform visits in patients' homes and facilities (ALF and ILF's) in their designated service area . You must have reliable transportation as travel is required daily.

Pittman schedule (2 on, 2 off, 3 on)

The following service area(s) are currently available:

• Bluffton/Beaufort area

About

We are a leading physician group serving South Carolina and Georgia, dedicated to delivering quality healthcare directly to patients in care facilities, homes, clinics, and virtual visits. Our services include comprehensive primary care, specialty services, and pharmacy support, tailored to meet diverse patient needs. Committed to excellence and innovation, our team collaborates closely with facilities and families to ensure accessible, coordinated, and compassionate care.

Why Choose a Career at Your Health?

Providing high quality care for our patients is the center of what we do, and we provide the same care for our employees. Here are some of the benefits that are available to our employees.

• Various Competitive Compensation Package with Bonus Opportunities
• Employer Matched 401K
• Free Visit & Prescriptive Services with HDHP Insurance Plan
• Employer Matched HSA
• Generous PTO Package
• Career Development & Growth Opportunities
• Vehicle allowance

What Are We Looking For?

Your Health is currently looking for a Registered Nurse to join our growing primary care family. A successful Nurse Case Manager will be able to perform these essential duties and responsibilities. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.

The following is a list of essential functions, which may be subject to change at any time and without
notice. Management may assign new duties, reassign existing duties, and/or eliminate function(s).

Area of Responsibility:

• Facilitate receiving all medical records from the patient’s primary provider and specialists.
• Review medical records.
• Complete consents with patients.
• Enroll patients in Care Management, if they meet eligibility criteria.
• Initiate a Care Management Plan of Care, if the patient is eligible.
• Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
• Complete AWV’s to be reviewed by the provider.
• Complete cognitive impairment screenings.
• Complete Social Determinants of Health (SDoH) assessments and/or screenings.
• Complete ACP’s to be reviewed with the patient by the provider.
• Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
• Evaluate for RPM devices, resources, or tools that may improve the patient’s quality of life.
• Communicate and coordinate care.
• Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments.
• Provide post-discharge education.
• Evaluate for adaptive equipment and DME.
• Evaluate for safe environment.
• Evaluation of acute condition(s) or follow-up from previous visit.
• Appropriately and accurately document and log Care Management activities. Work in conjunction with care team to keep the patients Care Management care plans up to date.
• Coordinate with the patient’s health care team, providers, physical and occupational therapists, home health or hospice representatives and other individuals in the patient’s care plan.
• Facilitate visits with appropriate provider or entity.
• Facilitate a telehealth visit with a provider for coordination of care, when necessary.
• Coordinate with the patient’s hospice interdisciplinary team and other individuals in the patient's care plan.
• Participate in IDG meetings, when necessary.

Qualifications:

• Must be a Registered nurse. License must be in good standing with appropriate board/issuer.
• A minimum of three (3) years clinical experience preferred.
• Experience in community settings preferred.
• Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
• Strong written and verbal skills.
• Basic computer knowledge.
• Ability to manage and demonstrate effective leadership skills.
• Should demonstrate good interpersonal and communication skills under all conditions and circumstances.
• Ability to foster a cooperative work environment.
• Team player with ability to manage multiple responsibilities and demonstrate sound judgment.
• Must be able to work flexible hours and travel between offices, facilities, etc. Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order