Registered Nurse Case Manager

Description:

Position Summary:

The Hospice Facility RN is responsible for coordinating and providing skilled nursing care to hospice patients residing in contracted skilled nursing facilities, assisted living facilities, memory care communities, and other residential care settings. The Facility RN serves as the primary hospice clinical liaison for assigned facilities, collaborating closely with facility staff, attending physicians, patients, families, and the interdisciplinary team (IDT) to ensure high-quality, compassionate end-of-life care.

The Hospice Facility RN promotes continuity of care, provides clinical expertise and education, strengthens facility relationships, and ensures compliance with all applicable regulatory standards and Peoples Hospice policies.

Essential Duties & Responsibilities

1. Assume primary responsibility for the clinical management of hospice patients residing in assigned facilities.
2. Conduct comprehensive admissions, routine nursing visits, recertification visits, and PRN visits in accordance with physician orders and the individualized plan of care.
3. Maintain an assigned group of contracted facilities and establish consistent clinical presence through routine rounding.
4. Serve as the primary hospice liaison between Peoples Hospice and assigned facility staff.
5. Build and maintain collaborative working relationships with facility administrators, Directors of Nursing, nurses, social workers, and caregivers.
6. Perform comprehensive nursing assessments and identify changes in patient condition requiring intervention or revision of the plan of care.
7. Develop, implement, evaluate, and revise individualized plans of care in collaboration with the patient, family, physician, facility staff, and interdisciplinary team.
8. Monitor pain and symptom management utilizing evidence-based hospice practices and recommend interventions to maximize patient comfort and quality of life.
9. Communicate significant patient changes promptly to the attending physician, Hospice Medical Director, Clinical Manager, and interdisciplinary team.
10. Coordinate hospice services including nursing, hospice aides, social work, chaplain, bereavement, volunteer, and therapy services.
11. Supervise hospice aide services and complete required supervisory visits in accordance with Medicare Conditions of Participation.
12. Participate in weekly Interdisciplinary Team (IDT) meetings by presenting patient status updates and collaborating on care planning.
13. Conduct care conferences with patients, families, facility staff, and physicians as appropriate.
14. Educate patients, families, and facility staff regarding hospice philosophy, disease progression, symptom management, medications, infection prevention, and end-of-life care.
15. Provide ongoing education to facility staff regarding hospice services, eligibility, documentation requirements, and best practices to strengthen collaborative partnerships.
16. Assist with hospice admissions originating from assigned facilities and facilitate smooth transitions of care.
17. Coordinate patient transfers, hospitalizations, discharges, revocations, and deaths while ensuring continuity of services.
18. Complete accurate, timely, and thorough clinical documentation within the electronic medical record in accordance with Medicare regulations, CHAP standards, and agency policies.
19. Ensure physician orders and certifications are obtained timely and accurately.
20. Participate in quality improvement activities and assist in maintaining compliance with regulatory and accreditation standards.
21. Identify opportunities to improve patient outcomes, customer service, and operational efficiency within assigned facilities.
22. Foster positive relationships with referral sources through professionalism, responsiveness, clinical expertise, and exceptional customer service.
23. Participate in orientation, required in-service education, competency validation, and continuing education programs.
24. Assist with home visits or community patient coverage during periods of staffing shortages or high census as directed.
25. Participate in the agency's on-call, weekend, and holiday rotation as assigned.
26. Respond promptly to changes in patient condition, urgent patient needs, and facility requests.
27. Perform other duties as assigned.

Required Qualifications

• Current unrestricted Registered Nurse license in the State of Florida.
• Minimum two (2) years of recent nursing experience.
• Hospice, home health, long-term care, palliative care, or acute care experience preferred.
• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal skills.
• Ability to work independently while maintaining collaborative relationships.
• Current CPR certification.
• Valid Florida driver's license.
• Reliable transportation with current automobile insurance.
• Ability to travel between assigned facilities.

Preferred Qualifications

• Previous hospice experience.
• Certified Hospice and Palliative Nurse (CHPN) certification or willingness to obtain.
• Experience working within skilled nursing facilities or assisted living facilities.
• Experience with electronic medical record systems.

Knowledge, Skills & Abilities

• Thorough understanding of hospice philosophy and end-of-life care.
• Knowledge of Medicare Hospice Conditions of Participation.
• Excellent symptom management and patient assessment skills.
• Ability to educate healthcare professionals and family caregivers.
• Strong organizational and time-management skills.
• Ability to prioritize multiple patient needs throughout the day.
• Professional demeanor and excellent customer service skills.
• Ability to build long-term partnerships with facility staff and referral sources.

Work Environment

This position primarily works within skilled nursing facilities, assisted living facilities, memory care communities, hospice inpatient settings, and other contracted residential facilities. Daily interaction with patients, families, physicians, facility personnel, and members of the interdisciplinary team is expected. Travel between assigned facilities is required.

Physical Demands

While performing the duties of this position, the employee is regularly required to stand, walk, bend, kneel, reach, lift, push, pull, and reposition patients. The employee must be able to lift or assist with lifting up to 50 pounds with or without reasonable accommodation. Manual dexterity, visual acuity, hearing, and verbal communication are essential to safely perform patient care responsibilities.

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