Per Diem RN Case Manager

Job Description About Us Our mission is to illuminate the final chapter of life through compassionate, expert care that combines clinical excellence with personalized, emotional support. We strive to create an experience where every ending is honored as a vital part of life’s journey. Illuminating the final chapter: Focused on making the end of life a meaningful and enriching experience, blending skilled medical care with a compassionate touch. Crafting personalized experiences: Emphasizing creative and individualized approaches to hospice care, guided by both expertise and empathy. Integrating the arts, nature, and personal passions: Implementing a holistic, creative approach to hospice care that complements our medical foundation, going beyond the purely clinical to nurture the whole person. Empowering families with tools for healing and remembrance: Supporting families with medical knowledge and emotional resources that extend beyond patient care, helping foster healing and memory-making as a lasting part of the experience. Job Purpose The RN Case Manager (RN) is part of the hospice nursing team and member of the Interdisciplinary group (IDG) that coordinates the care of the patient and family after identifying the physical, psychological, social, and spiritual needs of both. The RN initiates appropriate intervention and support for the patient and family upon admission and provides continuously appropriate, comprehensive, individualized, and responsive care plan. The nurse may also provide on-call visits, admissions, or deaths visits. Core Duties 1. Provide program coordination to ensure continual assessment and personalization of each patient’s and family’s needs from admissions throughout the hospice stay while collaboratively working with others to achieve patient, personal, and Company goals. 2. Understand and abide by state/federal/Medicare/ACCREDITATION hospice regulations, HIPAA/PHI regulations, Office of Civil Rights, and Company policy and procedures. 3. Provide initial, comprehensive and ongoing assessment of the impact of the terminal diagnosis on the patient’s physical, functional, psychosocial, and environmental needs and activities of daily living within the time frames as defined in the hospice regulations, company policies and defined in the plan of care. Assessments will include understanding the risk for pathological grief, cultural and spiritual implications, and verbal and non-verbal communication patterns. 4. Responsible for the coordination of care and ensuring continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care. Work with the IDG to develop, provide, integrate, and implement individualized written plans of care for patient and family and recommend revisions to the plan of care as necessary. Ensure the plan of care manages discomfort and provides symptom relief related to palliative and end-of-life care. The plan of care will be reviewed and updated as necessary to meet current patient care needs, no more than every 15 days. 5. Educate patient, family and primary care givers in the support of the patient including the disease process, self-care techniques, end-of-life care, and the processes for dealing with issues of ethical concerns. 6. Utilize the skills and resources of contracted personnel such as PT, ST, OT, Dietary, Pharmacy, and other services when deemed appropriate for patient outcomes. 7. Work with the patient’s physician(s) to manage care, intervention needs and outcomes, and receive orders when necessary. 8. Prepare and chart clinical notes that demonstrate progress toward established goals, successful or unsuccessful use of nursing interventions/medications/durable medical equipment/supplies/diseases process/family interventions. Utilize approved scales/medical terms/medical acronyms/labs to complete charting. Review previous charts from nursing and all disciplines to ensure full understanding of patient care. 9. Complete all charting within 24hrs of patient visit. 10. Supervise and work with licensed practical (vocational) nurses LPN/LVN/certified nursing assistants/social workers/Chaplains to establish appropriate levels of care and meet patients individualized plan of care and needs. 11. Participate in on-call needs, admissions, routine visits, death visits to meet patient and Company needs. 12. Participate in continuing education programs. 13. Communicate with coworkers and management in a productive, respectful, and factual manner. Being mindful of tone, body language, and words used. 14. Represent the Company in a profession #J-18808-Ljbffr AFFINITY HOSPICE LLC