Home Hospice RN Case Manager - Germantown, Mequon, Slinger

About the Role

As a Case Manager, you will identify and coordinate patient and family care to support terminally ill patients and their families in all hospice settings. The frequency of patient and family contacts will be determined by your assessment of need, with a minimum requirement of every 15 days. You will utilize teaching, assessment, and intervention skills to provide comfort care at the end of life and maximize the quality of life for patients and families.

Responsibilities

• Educate patients and families regarding disease processes and trajectory, disease management, hospice philosophies, signs and symptoms of decline, and end of life.
• Update the primary physician as indicated and according to agency, accreditation, state, and federal requirements.
• Continuously review all aspects of every patient on your caseload to ensure appropriate utilization of services and that hospice level of care criteria are met.
• Make referrals to other team members as appropriate.
• Administer medication and treatments as prescribed by the physician.
• Lead the interdisciplinary care group (IDG) specific to each patient and family on your caseload.
• Work within the IDG to develop, revise, and implement the patient’s Plan of Care (POC).
• Coordinate all services and collaborate with members of the interdisciplinary team to provide consistent patient care.
• Arrange for and/or recommend equipment, medical supplies, and other necessary items and services as indicated.
• Complete and update documentation in the electronic health record according to agency/department standards, accreditation, state, and federal guidelines.
• Accurately record the patient’s experience with a combination of assessments and narrative notes.
• Provide ongoing assessment of patient response to treatments, medications, and teaching, making appropriate changes in interventions and follow-up to meet patient needs.
• Update and revise the POC as indicated with supportive documentation.
• Communicate problems and changes in condition to physicians, supervisor, and other members of the IDG.
• Enter verbal orders from the physician or Advanced Practice Nurse (APN) into the Electronic Health Record.
• Supervise and perform Home Health Aide and licensed practical nurse supervisory visits according to agency standards.
• Instruct paraprofessional staff on a timely basis and in accordance with agency, state, and federal regulations.
• Facilitate the discharge planning process according to agency standards and utilize interagency/system and community resources to assure continuity of care after discharge.
• Wisconsin Only: Conduct OASIS assessments for Palliative Care patients and establish and update the plan of care. Conduct hospice initial and comprehensive assessments and establish and update the plan of care. Ensure continued skilled nursing/homebound criteria are met. Initiate appropriate preventive and rehabilitative nursing procedures.
• Utilize proper body mechanics, assistive devices, and safety techniques when performing patient positioning/repositioning and transporting duties, which require lifting and pushing/pulling.
• Orient and mentor new staff as requested.
• Demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served, including principles of growth and development over the life span.

Requirements

• Registered Nurse license issued by the state in which you practice.
• Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) (unless department leader determines it is not required).
• Valid driver’s license issued by the Division of Motor Vehicles.

Qualifications

• Completion of an accredited or approved program in Nursing.
• Typically requires 1-2 years of experience in nursing, including experiences in home health, hospice, medical/surgical, long-term care, emergency care/ICU, or oncology.

Skills

• Competent in the principles of deformity prevention, normal range of motion, body mechanics, and body alignment.
• Fundamental understanding of human behavior and the effects of stress upon individuals and groups.
• Excellent awareness and perception skills to assess patient needs, concerns, and recognize changes in health condition.
• Excellent communication and interpersonal skills.
• Excellent decision-making and critical thinking skills, with the ability to work independently and make sound judgments.
• Excellent prioritization and organizational skills.

Physical Requirements and Working Conditions

• Lift up to 50 lbs. from floor to waist.
• Lift up to 20 lbs. over the head.
• Carry up to 40 lbs. a reasonable distance.
• Push/pull with 30 lbs. of force.
• Perform a sliding transfer of 150 lbs. with a second person present.
• Work safely with people of various sizes and weights, with diverse and complex medical conditions and physical limitations.
• Physical agility and stamina to move about in confined spaces, including bending, kneeling, squatting, and occasionally reaching one or both arms over the head for long periods.
• Exposure to mechanical, electrical, chemical hazards, and blood and body fluids on a frequent basis.
• Required to wear protective clothing and equipment as needed.
• Functional speech, vision, hearing, and touch with the ability to use fine-hand manipulation skills.
• Operate all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected. It is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities. You may be required to perform other related duties.