RN CASE MANAGER

Reports to: Clinical Team Manager

Hours

Core work hours are 8am to 4:30pm Monday – Friday. Hours and days may vary depending on patient, organizational needs or if working scheduled weekend or holiday rotation. Participates in the weekend and holiday rotation.

Type of position: Full-time, Exempt

Summary

The RN Case Manager plans and delivers care to patients utilizing the nursing process of assessment, planning, interventions, implementation, and evaluation; and effectively interacts with patients, families, and other interdisciplinary team members while maintaining standards of professional nursing and clinical competency.

The RN Case Manager is responsible for identifying and coordinating patient/family care to support terminally ill patients and families in home, skilled nursing facilities and other residential care facilities.

Frequency of patient / family contacts will be at the discretion of the RN Case Manager and his/her assessment of need but will be a minimum of once per week.

The Case Manager endeavors to utilize teaching, assessment, and intervention skills to provide comfort care and maximize the quality of life for the patients and families.

Physical Demands

This job requires an employee to stand, talk and hear. There are frequent standing and walking, and occasionally an RN is required to sit, bend, kneel, stoop or crouch. This position requires frequent use of hands and fingers and may require reaching in front or above shoulders, feeling or grasping. The employee will frequently lift up to 35 pounds and occasionally move 100 pounds.

Work Environment

Work is performed in the Hospice Alliance residential facility, patient homes, skilled nursing facilities or any other place that a patient calls home. There is a potential for exposure to animals, smoke, unpleasant odors and a vulnerability to contagious diseases or infections. This position requires frequent driving which may present danger in inclement weather.

Essential Duties and Responsibilites

Provide direct care to patients as prescribed in the Interdisciplinary Plan of Care in order to maintain the highest level of comfort and quality of life and assuming primary responsibility for case management.

Evaluate and perform ongoing assessments and revise initial written plan of care with Interdisciplinary collaboration as the needs and conditions of the patient/family change in accordance with hospice regulations.

Authorize, coordinate, and supervise care, as prescribed in the Interdisciplinary Plan of Care, with contracted vendors in order to meet the needs of the patient.

Attend and participate in weekly IDT meetings.

Documents patient care reflecting nursing interventions, patient response to care, patient needs, problems, capabilities, limitations, progress toward goals and, patient/significant other teaching and the understanding of these instructions in the electronic medical record.

Assesses home care needs, being aware of the physical, emotional, and spiritual aspects and gathers data on social, economic, and cultural factors which may influence health, well-being and quality of life.

Assist patients, family members or other clients with concern and empathy; respect confidentially and privacy and communicate in a courteous and respectful manner.

Participates in the agency’s weekend rotation as prescribed by the needs of the agency to provide nursing service to clients when required outside of office hours.

Coordinates community resources and other agency disciplines participating in patient care.

Maintains ongoing effective communication with other hospice personnel and others who are involved with patient care

Knowledge of and availability to perform admissions, intake information and conduct consultations as needed including, accurate explanation of the hospice benefit/Medicare, completion of a physical assessment, and entering the information/documentation into the electronic medical record.

Participate in hospice and community health programs as requested to promote the growth and understanding of the hospice concept. This includes but is not limited to participation in the Hospice Alliance observation program that provides other health care professionals with the opportunity to observe and learn about hospice care, college partnerships, and other Hospice Alliance sponsored education events.

• Establish HHA plan of care as well as indirectly and directly supervise the plan of care per regulations.
• Follows Hospice Alliance policies, standards of practice and operational guidelines.
• Participation in Hospice Alliance town hall meetings, clinical team meetings, trainings, memorials and other events.
• Performs other duties as assigned.

Requirements

Education and/or Experience

Graduate of an accredited school of nursing. BSN preferred.

• Valid license as a Registered Nurse in the State of Wisconsin.
• Certification as a Certified Hospice and Palliative Care Nurse (CHPN) desired.
• Current Basic Life Support Certification
• Valid Driver’s License and auto insurance.
• Prior palliative care, home health and/or hospice experience is highly desirable
• A minimum of one-year recent professional nursing experience is recommended.
• Able to cope with emotional stress and be tolerant of individual lifestyles.
• Good written and verbal communication skills.
• Sensitive to the needs of terminally ill patients and families and one's own feelings about dying and death.
• Excellent time management and organizational skills are essential.
• Critical thinking skills and ability to solve problems.

Strong computer skills are required, such as email, and prior experience working with electronic medical records.