Hospice Nurse Case Manager

Job Description

Job Description

Job Title: Hospice Nurse Case Manager

Department: Mozaic Hospice

Job Objective:

The Hospice Nurse Case Manager is responsible for coordinating and managing individualized hospice care for an assigned caseload of patients and families. The Nurse Case Manager provides skilled nursing assessment and intervention, manages pain and other symptoms, coordinates the interdisciplinary plan of care, and promotes comfort, dignity, quality of life, and patient and family goals throughout the end-of-life experience.

The Nurse Case Manager serves as a primary clinical point of contact for patients, families, caregivers, physicians, and members of the interdisciplinary team and ensures that changes in condition and care needs are identified, communicated, and addressed promptly.

Minimum Qualifications:

Education: Graduate of an accredited school of nursing.

Licensure: Current license as a Registered Nurse in the State of Connecticut. Current driver's license and ability to travel throughout the service area as required.

Experience: Hospice, palliative care, home care, or related clinical experience preferred. Experience caring for patients with serious or life-limiting illness is highly desirable.

Essential Function:

The essential function of the Hospice Nurse Case Manager is to manage and coordinate comprehensive hospice nursing care for an assigned caseload while ensuring that each patient's individualized plan of care responds to changing needs, supports the patient's and family's goals, and promotes comfort, dignity, and quality of life.

Essential Duties and Responsibilities:

1. Manages an assigned caseload of hospice patients and coordinates care across the hospice interdisciplinary team.
2. Completes comprehensive and ongoing nursing assessments and identifies changes in physical, functional, psychosocial, emotional, spiritual, and safety needs within the RN scope of practice.
3. Develops, implements, evaluates, and updates the nursing component of the individualized hospice plan of care in collaboration with the patient, family/caregiver, attending physician, Hospice Medical Director, and interdisciplinary team.
4. Provides skilled nursing interventions focused on comfort, pain and symptom management, and quality of life.
5. Monitors patient response to medications, treatments, and interventions and communicates significant changes in condition promptly to the appropriate physician/provider and interdisciplinary team members.
6. Anticipates changes in patient needs and facilitates timely interventions to help prevent avoidable crises and support the patient's goals and preferred setting of care.
7. Educates patients and families/caregivers regarding disease progression, medications, symptom management, comfort measures, equipment, safety, and what to expect as the patient's condition changes.
8. Provides emotional support and guidance to patients and families/caregivers throughout the hospice experience while maintaining appropriate professional boundaries.
9. Coordinates services provided by hospice aides and other disciplines and ensures that care is consistent with the individualized plan of care.
10. Develops and oversees the hospice aide plan of care and performs required supervision in accordance with applicable requirements and agency policy.
11. Participates actively in interdisciplinary group/team meetings, providing current patient information and collaborating in the review and revision of the care plan.
12. Maintains timely, accurate, and complete clinical documentation consistent with applicable requirements, agency policy, and professional nursing standards.
13. Communicates and coordinates care with physicians, facilities, pharmacies, durable medical equipment providers, contracted providers, and other community partners as appropriate.
14. Coordinates hospice services when patients reside in or transition between home, assisted living, skilled nursing facilities, hospitals, or other care settings.
15. Identifies changes or concerns that may affect hospice eligibility or the patient's plan of care and communicates them to the Hospice Program Director, Medical Director, and interdisciplinary team as appropriate.
16. Participates in patient admissions, intake/triage activities, information calls, and other clinical coverage based on program needs.
17. Participates in the hospice on-call rotation as assigned and responds appropriately to urgent patient and family needs.
18. Identifies patient and family needs for social work, spiritual care, bereavement, volunteer, complementary therapy, and other hospice services and facilitates appropriate interdisciplinary referrals.
19. Supports patient and family understanding of hospice philosophy and participates in goals-of-care discussions within the nurse's role and scope of practice.
20. Patient visit frequency and other patient/family contacts are based on the patient's assessed needs, condition, goals of care, and individualized plan of care, with frequency adjusted as needs change.
21. Participates in quality improvement, clinical education, competency activities, case review, and other initiatives designed to improve patient care and hospice outcomes.
22. Maintains confidentiality and protects patient rights in accordance with HIPAA, applicable laws and requirements, and agency policies.
23. Demonstrates compassionate, culturally responsive, patient- and family-centered care and respects individual values, beliefs, preferences, and goals.
24. Performs other duties consistent with the position, professional scope of practice, skills and training, and the mission and goals of Mozaic.

Physical and Mental Requirements:

Must be able to perform the physical functions necessary to provide nursing care in home and community settings, including standing, walking, bending, reaching, and assisting with patient-care activities as appropriate. Must be able to travel between patient locations and function safely in varied home and facility environments.

Must be able to manage multiple priorities, respond appropriately to changes in patient condition and urgent situations, communicate effectively during emotionally difficult circumstances, and maintain professional judgment and composure when supporting patients and families experiencing serious illness, dying, death, and grief.

Environmental Conditions:

1. Rare exposure to blood, body tissue, or fluids.
2. Possible exposure to high/low temperatures.

This job description is not designed to cover or contain every possible listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.