Case Manager

Nurse Case Manager

The Nurse Case Manager is responsible for care coordination of patients along their continuum from point of entry through discharge. The CM will address issues related to appropriate and timely admission, discharge, and care for patients receiving inpatient and observation care and services at PPHS facilities. The Care Manager performs first level clinical reviews according to hospital approved clinical criteria and in accordance with the Care Management Program's Utilization Plan and payer specific requirements. He/she will address utilization of resources for efficient and effective care delivery at the appropriate level of care. The Care Manager collaborates with social work, physicians, nurses and multidisciplinary team, lending professional care management expertise to ensure quality, timely and cost effective case management for an identified patient population and addresses issues or patterns in patient readmission. In this role the Care Manager is accountable for facilitating clinical patient progression through a defined plan of care to achieve optimal outcomes. Under the direction of the Care Management Team Lead, the Director of Care Management, and through coordination with nursing, social work, physicians and other members of the interdisciplinary team, the Care Manager develops, facilitates and implements appropriate case management and discharge plans.

Qualifications:

• Associates degree in nursing, from a state accredited school. Required
• Bachelors degree in nursing, from a state accredited school. Preferred
• 3 or more years of general medical surgical nursing experience. Required
• 1 or more years of hospice or home care experience. Preferred
• Licenses and Certifications:
• RN - Registered Nurse and CCM - Certified Case Manager Required (Within 3 Years)
• Or, CHPN - Certified Hospice And Palliative Nurse. Required (Within 3 Years)
• BCLS - Basic Life Support. Required

Essential Functions:

• Collects data in a systematic and ongoing process
• Issues are identified and diagnoses are developed based on assessment data.
• Prioritizes data collection based on the patient's condition and needs.
• Identifies expected outcomes and plan based on diagnoses or issues.
• Directs the coordination of care across setting and among caregivers.
• Engages in teamwork as a team player and a team builder.
• Serves in key roles at work through shared decision making.
• Defines a clear vision including goals and plans and measures progress.
• Promotes nursing through participation in professional organizations.
• Documents and submits required information and data in a timely fashion.
• Clearly and accurately documents designated processes, policies, products, service offerings, etc.
• Ensures that documentation is tailored to expected readers / users.
• Uses correct terminology.
• Conforms to required style and format.
• Develops expected outcomes that provide direction for continuity of care.
• Involves patient/family and other disciplines to determine expected outcomes.
• Modifies expected outcomes based on changes in the assessment of the patient.
• Includes the patient and others involved in the care in the evaluation process.
• Evaluates the plan in relation to patient responses and expected outcomes. Documents the results of the evaluation.
• Uses the results of quality improvement activities in nursing practice.
• Uses creativity and innovation in nursing practice to improve care delivery.
• Incorporates evidence based knowledge to initiate change in nursing practice.
• Participates in quality improvement activities.
• Accountable for individual practice and delegation to provide optimum care.
• Practices with compassion and respect.
• Primary commitment is to advocate for the patient, family and community.
• Assures patient safety through competency and growth of self and others.
• Contributes to a healthy work environment through shared decision making.
• Collaborates with other health professionals to meet healthcare need.
• Adheres to established standards of interdisciplinary nursing practice and the policies and procedures of Phoebe Sumter Hospice and Phoebe Putney Health System.
• In collaboration with the patient's attending physician, if any, and the Hospice physician, the RN Case Manager develops an individualized comprehensive plan of care that includes interventions and goals based on the findings of the initial and updated comprehensive assessment(s). Determines the scope and frequency of interdisciplinary services needed based on the patient's and family's goals and needs identified in the initial and updated comprehensive assessment(s). Assumes responsibility for compliance with Federal and State regulations.
• Provides professional interdisciplinary nursing care by utilizing all elements of nursing process. Completes, maintains, and submits accurate and relevant clinical documentation in the EMR at the point of care regarding patient's and family's condition and the care provided in a timely manner.
• Administers and documents medications and treatments as prescribed by the physician.
• Obtains orders from the patient's attending physician and the Hospice medical director based on an evaluation of the patient's physical, psychosocial, and emotional status related to the terminal illness and related conditions.
• Provides education to patients and families regarding medications, treatments and procedures, disease processes, and end-of-life care.
• Participates in the admission process as needed, which may include but may not be limited to: obtaining referral information, explaining the hospice program and obtaining the Notice of Election of Hospice Benefit, Consent for Care, and Assignment of Benefits from the patient/representative, and performing an initial and/or comprehensive assessment to determine the immediate and on going needs of the patient/family (e.g., supplies, medications, equipment, referrals, etc.)
• Coordinates 24/7 care management across all settings, ensuring all IDGT team members, and other care facility members, collaborate to follow the hospice palliative care plan.
• Participate in the inquiry, referral and admission processes.
• Provide dignified end-of-life care for patients, educate on expected signs and symptoms of end-stage disease, the dying process, family care giving, and patient's death.
• Actively participates in the hospice's QAPI program.
• Provide outreach education about hospice services in the community to both professional and lay audiences.
• Performs additional duties as needed.
• Participates in on-call duties as defined by the on-call policy, as needed.
• Actively participates in Quality Assessment Performance Improvement (QAPI) activities.
• Assumes responsibility for personal growth and development and maintains professional knowledge and practice skills through attendance and participation in continuing education and in-services.
• Provide full hospice services during evening, weekend and other requested shifts, including routine visits, admissions, discharges, death attendance, and collaboration with care facilities and hospice IDG.
• Maximizes the utilization of EMR for all documentation at point of care.
• Knowledgeable about federal and state hospice regulations and practices to ensure compliance as a case manager individually and as the RN responsible for care management across team and all care settings.
• Assesses and educates patients/families about safety in the home.
• Utilizes appropriate processes to ensure safety of self and team in the field.
• Comfortable making autonomous decisions in the field, and appropriately collaborating with patient/family physicians, interdisciplinary group (IDG) members and Phoebe support departments as needed to ensure quality, timely patient/family care.
• Effectively handles conflict between team members, partners in care.