Nurse Case Manager

Job Description

Job Description

Primary Responsibilities

As a member of the interdisciplinary team, the RN Case Manager works under the general direction of the DOCS, the Patient Care Coordinator, and the attending physician in the provision of skilled nursing assessment, planning and care in order to maximize the comfort and health of patients and families. The RN Case Manager is responsible for identifying patient/family needs and for providing supportive care in accordance with the attending physician's orders and plan of care and Crater Community Hospice, Inc.'s policies and procedures.

Essential Functions

• Assumes primary responsibility for a patient/family caseload that includes the assessing, planning, implementing, and evaluating phases of the nursing process.
• Assures that the initial in-home evaluation of any patient requiring services is performed by a Registered Nurse.
• Assigns home health aides and other nursing support staff to individual patients and/or supervises the delivery of skilled nursing services.
• Re-evaluates the patient's nursing needs per visit and reports changes in the patient's physical or mental condition to the attending physician and to hospice employees and contractors involved in the patient's care. Informs the DOCS/Patient Care Manager of unusual or potentially problematic patient/family issues.
• Initiates communication with attending physicians, other hospice staff members and other agencies as needed to coordinate optimal care and use of resources for the patient/family.
• Maintains regular communication with the DOCS/Patient Care Manager to review caseload.
• Initiates the patient's plan of care in accordance with nursing needs specified in the approved plan of care including therapy needs.
• Assures patient has proper supplies, equipment and medications and they are all utilized correctly.
• Assesses and initiates preventive and rehabilitative nursing procedures as needed.
• Documents all daily visits and/or contacts into the medical record system at the time of the visit or before ending the shift.
• Assesses need for and provides specific written instructions for the CNA who will deliver services to the patient.
• Conducts in-home supervision of the home health aide at least every 14 days and documents in the patient's medical record whether services are being delivered in an appropriate manner, consistent with hospice nursing service policies and procedures. Documents the actions taken when delivered services are found to be unacceptable or inconsistent. Ensures that contracted CNA in-home supervisory visits are conducted by the contractor.
• Obtains data on physical, psychological, social, and spiritual factors that may influence patient/family health status and incorporate that data into the plan of care.
• Maintains up-to-date patient records so that problems, plans, actions and goals are accurately and clearly stated, and changes are reflected as they occur.
• Seeks input from other team members regarding the patient plan of care to obtain additional knowledge and support.
• Accepts responsibility for coordinating physical care of the patient by teaching primary caregivers, volunteers, employed caregivers, or by providing direct care as appropriate, for nursing or personal care needs.
• Attends IDG conferences and facilitates discussion of issues to update the care plan.
• Provides appropriate support at time of death and during period of bereavement.
• Participates in Crater Community Hospice orientation and in-service training programs for hospice employees assigned to the nursing service.
• Participates in agency quality assurance reviews and evaluations of the nursing services and other community programs as requested to promote professional growth and understanding of hospice care.
• Completes 15-day IDG care plans on all assigned patients and re-evaluates and prepares plan of care for MD review and signature.

Knowledge, Skills, and Education Requirements

• Graduate of an accredited school of nursing and licensed to practice in the state of Virginia, bachelor’s degree in nursing preferred.
• Experience in home health, hospice, oncology, or critical care preferred with at least 3 years’ experience as a registered nurse.
• Current CPR certification.
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served. The individual must demonstrate knowledge of the principles of growth and development of the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in the organization's policies and procedures.
• Well-versed computer literacy with in-depth knowledge and experience with electronic medical records programs.

Work Environment & Physical Demands

Situated in a professional medical environment and/or in patient homes of unknown environments yet may have the potential for locations in high crime areas, poor environmental conditions, and non-handicapped accessible sites. This role is frequently active with occasional lifting and/or carrying up to 50 lbs. The individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions. Frequent local travel with mileage stipend as required for patient care.

Crater Community Hospice, Inc. Mission Focus

All employees are responsible for extending the Crater Community Hospice mission: To share our passion for improving quality of life for those who are facing a life-limiting illness; as well as our core values of Compassion, Respect, Accountability, Teamwork, Empathy and Reliability.