Registered Nurse Case Manager

Job Details Job Location: Spicewood - Austin, TX 78759 Position Type: 40 HRS - 1 FTE Job Shift: M-F 8A-5P DEPARTMENT: Clinical Services REPORTS TO: Team Leader 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 Provides professional nursing care for hospice patients in the homecare and assigned facility settings. Performs 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 any risk for pathological grief, cultural and spiritual implications, and verbal and non verbal communication patterns. Performs comprehensive nursing assessments, including vital signs, pain assessment, breath sounds, and other clinically indicated evaluations. Triage patient care concerns and determines appropriate interventions. Initiates preventive, comfort focused, and rehabilitative nursing procedures as needed and facilitates transition to another level of hospice care when appropriate. Develops, maintains, and updates individualized plans of care, performing specialized nursing skills related to palliative and end of life care, symptom management, and comfort measures. Consults with and educates 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. Provides specialized training to staff and/or caregivers to ensure adequate and safe care. Performs ongoing evaluation of patient and family response to care and adjusts interventions accordingly. Provides psychosocial support to patients and families throughout the course of care. Provides preparation and support for the patient’s death; pronounces death in accordance with state regulations, provides postmortem care, and handles the body and death event with respect, dignity, and in accordance with patient/family/caregiver wishes. Utilizes proper infection control and bag technique during all in person visits. Reports 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. Performs point of service documentation and completes/signs all documentation according to agency protocol. Complies with minimum weekly visit requirements per company protocol. Conducts 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. Provides ongoing education in assigned facilities, including training for facility staff on hospice philosophy, symptom management, communication expectations, and care coordination processes. Coordinates nursing, personal, and homemaker care for hospice patients in the homecare and assigned facility settings. Attends IDT meetings; coordinates patient and family care and services, prioritizing needs in collaboration with the interdisciplinary team. Informs the physician and other team members of changes in the patient’s condition, needs, and response to interventions. Determines the scope, frequency, and type of services needed based on patient acuity and patient/family goals of care. Coordinates personal care services, durable medical equipment, medications, and medical supplies to ensure timely and appropriate delivery. Uses a case management approach, referring to other disciplines as needed (e.g., Nutritionist, PT, OT, SLP) to support comprehensive care. Provides supervision of care delivered by CNAs, LVNs, and homemakers in accordance with regulatory guidelines and agency standards. Documents patient assessments, contacts, physician orders, and clinical/progress notes in a timely manner, demonstrating progress toward established goals. Ensures hospital and facility charts (hospitals, long term care facilities, assisted living facilities) include documentation after each patient visit, as applicable. Acts 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. Collaborates with Hospice Austin and hospital/facility staff regarding discharge planning, ordering DME, medications, and coordinating safe transitions of care. Evaluates personal needs for support and self care, using identified systems and resources to maintain professional well being. Recognizes and maintains professional boundaries in relationships with patients, families, and caregivers. Assists in developing and implementing discharge plans, providing advance notice to the patient and family according to regulatory standards. Conducts 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. Provides 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. Conducts 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