RN Case Manager, Full-time

Job Description

Job Description

The schedule for this role is Monday-Friday 8 am to 5 pm.
This is a full-time professional position. This position leads the interdisciplinary team in providing patient centered care to assigned hospice patients. Position is responsible for developing and implementing appropriate care plans and interventions based on the goals of the patient and the interdisciplinary team. All work will be performed in a manner consistent with agency, nursing and regulatory standards and regulations.

Responsibilities

• Plan, provide, supervise and document safe, competent, and compassionate hospice nursing care for patients in accordance with physician orders and established policies and procedures.
• Use professional nursing judgment to individualize the plan of care based on assessment of the patient's unique needs and response to care.

• Responsible for providing, and documenting, appropriate and relevant end of life information and education to patients and their families in compliance with current Centers for Medicare and Medicaid Services CMS Conditions of Participation (CoPs).
• Works collaboratively with IDG and other Transitions LifeCare (TL) departments in achieving patient care goals.
• Responsible for overseeing and coordinating all disciplines within the patient’s care team in relation to the patient’s plan of care.
• Participate in own professional development by maintaining required competencies, identifying learning needs and seeking appropriate assistance or educational offerings.
• Delegate tasks and supervises the activities of LPNs and Hospice Aides, as needed.
• Responsible for professionally managing time, people and technology.
• Monitors and manages the appropriate use of patients’ medical equipment, supplies and medications.
• Collaborates with other Interdisciplinary Group (IDG) members to determine the patient’s level of care and coordinate the appropriate utilization of contract services.
• Participate in the identification of clinical or operational performance improvement opportunities and in performance improvement activities.
• Actively participates in the orientation and training of new employees of all disciplines.
• Responsible for following current CoPs as related to Certified Nursing Assistant (CNA) supervision and LPN supervision.
• Performs other duties as assigned by supervisor.

Expectations

• Model professionalism and empathy by consistently demonstrating compassion, respect, teamwork, and dedication in all interactions with coworkers, customers, and partners.
• Adhere to all TL policies, procedures, and organizational guidelines, ensuring compliance in daily work and decision‑making.
• Deliver care and services in accordance with ACHC Standards and Medicare Conditions of Participation when applicable to your role.
• Comply with all relevant state and federal laws, regulations, and professional standards within your defined scope of responsibility.
• Promptly communicate concerns, issues, or potential risks to your immediate supervisor or another member of the management team to support a safe and effective work environment

Requirements

• Registered Nurse with current NC license; BSN preferred.
• Minimum 2 years recent clinical experience. Hospice and/or home health or nursing home experience or equivalent preferred.
• Hospice Nurse Certification preferred.

• Able to independently seek out resources and work collaboratively
• Able to communicate clearly with patients, families, visitors, IDG team, physicians, facility staff, leadership and others
• Able to teach patients and families in accordance with the nursing plan of care

• Knowledgeable about reimbursement sources, Medicare regulations, licensing laws, and accreditation standards.
• Competent computer skills.
• Current CPR certification.
• Must have reliable transportation.
• Must be able to travel to enter and function in the homes/facility of any patient/family in the service area to assess and provide care to all patients.
• May be required to lift and/or carry items up to 50 pounds.
• Must have sensory abilities to complete physical assessment, communicate with patient/family care providers and physician and to complete the reporting and follow-up documentation responsibilities of the job.
• Workdays and scheduled hours with weekend and holiday commitments as outlined in Employee Information Agreement.

Environmental Factors

• Tasks with potential for exposure to blood borne pathogens.
• May be potentially exposed to communicable diseases or bodily fluids.