Registered Nurse Case Manager

Job Description

Job Description

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES
Patient Care
1. Completes an initial, comprehensive and ongoing comprehensive assessment of patient
and family to determine hospice needs. Provides a complete physical assessment and
history of current and previous illness(es).
2. Provides professional nursing care by utilizing all elements of nursing process.
3. Assesses and evaluates patient’s status by:
A. Writing and initiating plan of care
B. Regularly re-evaluating patient and family/caregiver needs
C. Participating in revising the plan of care as necessary
4. Initiates the plan of care and makes necessary revisions as patient status and needs
change.
5. Uses health assessment data to determine nursing diagnosis.
6. Develops a care plan that establishes goals, based on nursing diagnosis and incorporates
palliative nursing actions. Includes the patient and the family in the planning process.
7. Initiates appropriate preventive and rehabilitative nursing procedures. Administers
medications and treatments as prescribed by the physician in the physician’s plan of care.
8. Counsels the patient and family in meeting nursing and related needs.
9. Provides health care instructions to the patient as appropriate per assessment and plan.
10. Assists the patient with the activities of daily living and facilitates the patient’s efforts toward
self-sufficiency and optional comfort care.
11. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to
coordinate patient care for assigned caseload.

Communication
1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s
condition and care given. Records pain/symptom management changes/outcomes as
appropriate.
2. Communicates with the physician regarding the patient’s needs and reports changes in the
patient’s condition; obtains/receives physicians’ orders as required.
3. Communicates with community health related persons to coordinate the care plan.
4. Teaches the patient and family/caregiver self-care techniques as appropriate. Provides
medication, diet and other instructions as ordered by the physician and recognizes and
utilizes opportunities for health counseling with patients and families/caregivers. Works in
concert with the interdisciplinary group.
5. Provides and maintains a safe environment for the patient.
6. Assists the patient and family/caregiver and other team members in providing continuity of
care.
7. Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet
the emotional needs of the patient and family/caregiver.
8. Attends interdisciplinary group meetings.
Additional Duties
1. Participates in on-call duties as defined by the on-call policy.
2. Ensures that arrangements for equipment and other necessary items and services
are available.
3. Supervises ancillary personnel and delegates responsibilities when required.
4. Assumes responsibility for personal growth and development and maintains and upgrades
professional knowledge and practice skills through attendance and participation in
continuing education and Inservice classes.
5. Fulfills the obligation of requested and/or accepted case assignments.
6. Actively participates in quality assessment performance improvement teams and activities.