RN Case Manager - Patient Care

You can Make A Difference in the lives of others!
At Heart to Heart Hospice, we provide "Compassionate Care from Our Hearts to Yours." Our employees enhance the lives of patients with life-limiting illnesses and their loved ones,during a time when compassionate care is needed most. We are dedicated to making a difference in the lives of employees, offering the opportunity to be associated with caring teammates, and creating positive contributions in each community we serve.

Job/Position Description

RN Case Manager
Job Title: RN Case Manager Dept: Clinical Reports To: Patient Care Manager Supervisory Responsibilities: X Yes No FLSA Status: X Exempt Non-Exempt

Position Summary

Primary functions are to administer skilled nursing care for clients of all ages in their place of residence, coordinate care with the

interdisciplinary team, patient/family and referring agency; and assumes the responsibility for coordination of care.

QUALIFICATIONS AND EDUCATION REQUIREMENTS

• Graduate of an accredited Diploma, Associate or Baccalaureate School of Nursing
• Current State license as a Registered Nurse
• Current State Drivers License

• Two years of experience as an RN preferred in a healthcare/clinical setting
• Nursing skills as defined as generally accepted standards of practice
• Strong critical thinking, organizational, interpersonal, and communication skills
• Must be highly motivated, self-directed, flexible, and able to work well and participate in a multidisciplinary group setting
• Ability to work autonomously
• Flexible schedule for late afternoon admits
• Experience in EMR a plus
• Specialized skills preferred in palliation and end-of-life
• Proof of current CPR and maintain a current status
• Must meet mandatory CE requirements of licensing board per state and maintain a current status
• Must read, write and comprehend English

• Must have reliable transportation and provide ongoing valid and current auto liability insurance

ESSENTIAL DUTIES:

• Initial and ongoing comprehensive assessments of the impact of the terminal disease on the patients physical, functional,

psychosocial, and environmental needs and ADLs, i.e., risk for grief, cultural and spiritual, verbal and non-verbal

• Implement the individualized POC and recommend revisions to the plan as necessary
• Collaborates care amongst patient/patient caregiver, physicians and healthcare professionals
• Care Manager and attending physician and hospice physician regarding the eligibility and appropriateness of client for hospice services
• Consult with and educate the patient and family regarding disease process, self-care techniques, end-of-life care, nutrition and dietary needs
• Provide training to other staff as needed
• Initiate appropriate preventive and rehabilitative nursing procedures
• Prepare clinical and progress notes that demonstrate progress toward established goals
• Attend Inter-Disciplinary Group (IDG) meeting, coordinate and participate in the patient care planning process, prioritization of needs and collaborates with IDG to promote coordination of patient care
• Use of case management approach and referring to other services as needed
• Inform physician and other personnel of changes in the patient's needs and outcomes of intervention, while evaluating

patient/family response to care

• Determine scope and frequency of services needed based on acuity and patient/family needs
• Assess ability of the caregiver to meet the patient's immediate needs upon admission and throughout care
• Evaluate own needs for support and using identified systems to meet the need
• Communicate information using current process and technology available to the organization
• Apply specific criteria for admission and re-certification to hospice care to establish appropriate levels of care and the patient's eligibility
• Perform on-call responsibilities and provide on-call service to patients/families as assigned
• Supervisor of LPN/LVN and Hospice Aide per regulations
• In EMR/HCHB, all visits are to be completed and synced same day
• Utilize excellent customer care skills with internal and external customers, including using proper phone etiquette
• Promote positive, respectful communication to all staff, referral sources, patients and families
• Abide by and demonstrate the company Mission and 12 Heart's Desires through both behavior and job performance on a day-to-day basis
• Performance of other duties as required
• Participate in all mandatory staff in-services and meetings
• Maintain compliance with internal annual education requirements (Heart to Heart University/Relias)
• Timely submission of all documentation
• Conduct all business activities in a professional and ethical manner
• Ensure overall compliance with local, state and federal laws, Medicare regulations, and established personnel policies and procedures

WORKING CONDITIONS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.


Works in patients home in various conditions; possible exposure to blood and bodily fluids and to infectious diseases; ability to work flexible schedule; ability to travel locally; some exposure to unpleasant weather; PRN emergency call.

Prolonged standing and walking required, with ability to lift up to 50 lbs and move patients. Requires working under some stressful

conditions to meet deadlines and patient needs, and to make quick decisions and resource acquisition; meet patient/family individualized psycho social needs. Requires hand-eye coordination and manual dexterity.

EMPLOYEE ACKNOWLEDGMENT

I acknowledge by my signature that I have read and understand the duties and responsibilities, physical demands, and work environment of the position and all other standards expected of me. I understand this job description in no way states or implies that these are the only duties to be performed by me in this position. Nothing in this job description restricts the right of an authorized person to assign or reassign duties and responsibilities to this job at any time. I also understand that nothing in this job description is meant to create a contract of employment or alter in any way the employment-at-will status of the employee in this job.

It is this Agency's policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, sex, marital status, national origin or disability.