Job Description Summary
The Registered Nurse Case Manager plans, organizes and directs hospice care and is experienced in nursing, with emphasis on community health education/experience. The registered nurse builds from the resources of the community to plan and direct services to meet the needs of individual and families in their home setting.
· Evaluates and performs an initial comprehensive and ongoing assessment of patient and family to determine hospice needs when assigned.
· Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions to maintain the highest level of comfort and quality of life including the patient and the family in the planning process.
· Regularly re-evaluates patient and family/caregiver needs collaborating with the interdisciplinary team and revising the plan of care as necessary.
· Administers medications and treatments as prescribed by the physician according to the plan of care.
· Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers.
· Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care.
· Ensures that arrangements for equipment and other necessary items and services
· Teaches the patient and family/caregiver self-care techniques as appropriate.
· Assesses home care needs and maintains a safe environment for the patient.
· Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition.
· Communicates with community resources and vendors to coordinate the care plan to meet the patients’ needs.
· Maintains compliance by completing, maintaining and submitting accurate data including ongoing assessments and relevant clinical notes regarding patient’s condition and care given in the electronic medical records system.
· Records pain and symptom management changes/outcomes as appropriate.
· Uses equipment and supplies efficiently and in a cost effective manner to support the organizations financial performance.
· Acts as Case Manager when assigned and assumes responsibility to coordinate patient care for assigned caseload.
· Acts as a liaison between the patient and family/caregiver and other team members in providing continuity of care.
· Attends and participates in weekly interdisciplinary group meetings.
· Participates in the agency’s on-call rotation as scheduled to provide nursing care to patients outside office hours.
· Maintains professional knowledge and practice skills participating in continuing education and in-services.
· Actively participates in quality assessment performance improvement teams and activities.
· Orients new personnel hired as assigned.
· Participates and promotes hospice in the community to promote the growth and understanding of the hospice concept.
· Maintains effective working relationships with employees, physicians, vendors, and potential referral and payer sources.
· Knowledge of and adherence to all policy and procedures.
· Maintains compliance by documenting accurately and timely within the organization’s electronic health record.
· Lives the Mission, strives to achieve the Vision and exemplifies the Core Values of the organization.
· Works toward exceeding chosen Pillar goals in the areas of Employee Satisfaction, Customer Satisfaction, Quality Service, Compliance, Growth and Financial Performance.
· Knowledge of and adherence to the employee Code of Conduct and Code of Ethics.
The above statements are intended to be a summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
· Registered nurse with current licensure with no restrictions to practice professional nursing in the state.
· Must have experience as a Registered Nurse, at least one of which is in the area of home care or hospice nursing preferred..
· Maintains a current CPR certification.
Primarily frequent in nature with exerting up to fifty pounds of force occasionally, and/or up to twenty pounds of force frequently, and/or up to ten pounds of force constantly to move objects: reaching, lifting, carrying, handling, walking, sitting, standing, bending, squatting, climbing, kneeling, and twisting. Position may require pushing and pulling up to 300 lbs. Frequent to continuous speaking, hearing, near visual acuity, far visual acuity, depth perception, typing and driving.