Registered Nurse Case Manager

Position Summary The hospice RN provides comprehensive, professional nursing care to patients in both homecare and assigned facility settings, including conducting admissions visits for new patients and delivering ongoing education to facility staff. The role includes performing thorough initial and ongoing assessments, developing and updating individualized plans of care, managing symptoms, and offering psychosocial and end‑of‑life support to patients and families. The nurse consults with and educates caregivers and facility partners on disease processes, comfort measures, and hospice philosophy, ensuring consistent, high‑quality care across settings. Using a case‑management approach, the RN coordinates all aspects of patient care such as bath aide services, DME, medications, and interdisciplinary referrals while maintaining timely, accurate documentation in both agency and facility records. The nurse collaborates closely with physicians, interdisciplinary team (IDT) members, hospital and facility staff, and other care partners to communicate changes in condition, support discharge planning, and facilitate smooth transitions of care. The role includes supervising CNAs, LVNs, and homemakers, maintaining professional boundaries, and practicing effective self‑care to sustain high‑quality clinical performance. Duties and Responsibilities Provide professional nursing care for hospice patients in the homecare and assigned facility settings. Perform initial 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, including risk for pathological grief, cultural and spiritual implications, and verbal and non‑verbal communication patterns. Conduct comprehensive nursing assessments, including vital signs, pain assessment, breath sounds, and other clinically indicated evaluations. Triage patient care concerns and determine appropriate interventions. Initiate preventive, comfort‑focused, and rehabilitative nursing procedures as needed and facilitate transition to another level of hospice care when appropriate. Develop, maintain, and update individualized plans of care, performing specialized nursing skills related to palliative and end‑of‑life care, symptom management, and comfort measures. Consult with and educate patients and caregivers, including hospital, alternate living facility, or home health staff, regarding disease process, self‑care techniques, end‑of‑life care, comfort measures, medication use and side effects, and ethical considerations. Provide specialized training to staff and/or caregivers to ensure adequate and safe care. Perform ongoing evaluation of patient and family response to care and adjust interventions accordingly. Provide psychosocial support to patients and families throughout the course of care. Assist with preparation and support for the patient’s death; pronounce death in accordance with state regulations, provide postmortem care, and handle the body and death event with respect, dignity, and in accordance with patient/family/caregiver wishes. As needed and depending on current caseloads, may be asked to provide nursing care to pediatric patients. Utilize proper infection control and bag technique during all in‑person visits. Report adverse events (complaints, infections, falls) to the Team Leader or Quality Department as soon as possible but no later than 24 hours of obtaining information. Perform point of service documentation and complete/sign all documentation according to agency protocol. Comply with minimum weekly visit requirements per company protocol. Conduct admissions visits for new patients in assigned facilities, completing initial comprehensive assessments, initiating the plan of care, and ensuring a smooth transition onto hospice services. Provide ongoing education in assigned facilities, including training for facility staff on hospice philosophy, symptom management, communication expectations, and care coordination processes. Coordinate nursing, personal, and homemaker care for hospice patients in the homecare and assigned facility settings. Attend IDT meetings; coordinate patient and family care and services, prioritizing needs in collaboration with the interdisciplinary team. Inform the physician and other team members of changes in the patient’s condition, needs, and response to interventions. Determine the scope, frequency, and type of services needed based on patient acuity and patient/family goals of care. Coordinate personal care services, durable medical equipment, medications, and medical supplies to ensure timely and appropriate delivery. Use a case‑management approach, referring to other disciplines as needed (e.g., Nutritionist, PT, OT, SLP) to support comprehensive care. Provide supervision of care delivered by CNAs, LVNs, and homemakers in accordance with regulatory guidelines and agency standards. Document patient assessments, contacts, physician orders, and clinical/progress notes in a timely manner, demonstrating progress toward established goals. Ensure hospital and facility charts include documentation after each patient visit, as applicable. Act as a liaison between patients, physicians, hospital staff, long‑term care facility staff, and other care team members to facilitate ongoing clinical care and effective communication. Collaborate with Hospice Austin and hospital/facility staff regarding discharge planning, ordering DME, medications, and coordinating safe transitions of care. Evaluate personal needs for support and self‑care, using identified systems and resources to maintain professional well‑being. Recognize and maintain professional boundaries in relationships with patients, families, and caregivers. Assist in developing and implementing discharge plans, providing advance notice to the patient and family according to regulatory standards. Conduct admissions visits for new patients in assigned facilities, coordinating with facility staff to ensure a smooth onboarding process and accurate initiation of the plan of care. Provide ongoing hospice education in assigned facilities, including training on symptom management, communication expectations, hospice philosophy, and care coordination workflows to support high‑quality, consistent care. Conduct other duties as assigned. Qualifications Graduation from an approved school of professional nursing as determined by the Board of Nurse Examiners. Unrestricted license as a Registered Nurse by the Texas Board of Nurse Examiners. Valid Texas driver’s license, auto liability insurance and safe driving record. CPR certification. Preferred Skills One‑year previous nursing experience. Previous hospice or home health experience. #J-18808-Ljbffr