Registered Nurse (RN) Hospice Case Manager

Summary

Responsible for coordinating and directing the delivery of care for an assigned case load of patients who are receiving services in the home setting in collaboration with the interdisciplinary care team. Determines the appropriate level of the care for the patient as well as skilled need for services ordered based on Conditions of Participation. Initiates, reviews, evaluates, and revises the established plan of care in collaboration with the physician and the interdisciplinary team for appropriate care plan progression aimed at achieving patient goals, quality metrics, and level of care transition. Performs initial and ongoing assessments and skilled treatments and interventions as ordered by the physician and provides patient/caregiver education aimed at achieving patient goals/outcomes.

Job Duties

• Coordinates and directs the delivery of care for an assigned case load of patients who are receiving services in the home setting in collaboration with the interdisciplinary care team.
• Initiates, reviews, evaluates, and revises the established plan of care in collaboration with the physician, interdisciplinary team for appropriate care plan progression aimed at achieving patient goals, quality metrics, and level of care transition.
• Works in collaboration with other network entities to ensure appropriate delivery of patient care and care progression.
• Responsible for completing data collection as per CMS regulation with a high level of accuracy that reflects quality outcomes measures and appropriate financial reimbursement for services.
• Formulates an individualized plan of care according to physician orders that incorporates the analysis of assessment data and current scientific findings.
• Determines the appropriate level of care for the patient as well as skilled need for services ordered based on Conditions of Participation.
• Relays significant changes in patient status to the physician and other members of the interdisciplinary care team in a time period consistent with patient needs.
• Delivers patient care based on the medical plan of treatment established by the physician and protocols using a patient family centered approach.
• Provides educational opportunities for patients, families, and clinical staff focusing on end-of-life issues, palliative care, advance directives, chronic disease management, pain management, symptom control, home care, hospice, and discharge planning.
• Promotes patient/caregiver autonomy.
• Evaluates effectiveness of teaching and modifies education based on patient needs and goals.

Minimum Qualifications

• Specialized Diploma NLN approved/accredited nursing program
• 1 year recent experience providing direct care in a healthcare setting
• Knowledge of patient education techniques and principles
• Ability to take initiative and function independently without direct supervision
• Ability to actively participate as a member of a care team
• Exhibit excellent time management and organizational skills
• Ability to manage a caseload of patients as per agency standards
• Ability to travel to patient care assignments
• Knowledge of Conditions of Participation
• Knowledge of and skill in completing regulatory data set collection with a high level of accuracy
• Highly skilled in verbal and nonverbal communication
• Ability to facilitate difficult and complex communication related to goals of care
• BLS - Basic Life Support AHA - American Heart Association Within 30 Days
• RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire
• DL - Driver's License_PA - State of Pennsylvania Upon Hire or DL - Driver's License_NJ - State of New Jersey Upon Hire

Preferred Qualifications

• Associate's Degree Nursing or Bachelor's Degree Nursing
• 1 year experience as a home health or hospice Registered Nurse
• Knowledge and ability to navigate multiple computer applications and EMR platforms
• AMB-BC- Ambulatory Care Nursing-Board Certified - American Nurses Credentialing Center within 3 Years or CHPN - Certified Hospice and Palliative Nurse - Hospice and Palliative Nurses Association within 3 Years

Physical Demands

Lift and carry 40-50 lbs. Examples: Push/pull patients on bed, stretcher (requires 29 lbs. push force), lateral transfers up to 50 lbs. of the patient's weight. Frequent to continuous standing/walking. Patient transporters can walk 8-10 miles per shift. Patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.