Hospice RN Nurse Case Manager

We are seeking a Registered Nurse to service our patients throughout the 29138, 29166, 29006, 29070, 29054, and 29072 areas.

About the role

The Nurse Case Manager is a critical part of the patient’s care team, visiting patients in their homes, long-term care facilities, and other settings to evaluate patients and initiate telemedicine visits. This role requires daily travel to patients' locations, including ALFs and ILFs within the designated service area. Reliable transportation is required.

This is a full-time, salaried position working 12-hour shifts.

About us

We are a leading physician group serving South Carolina and Georgia, dedicated to delivering quality healthcare directly to patients in care facilities, homes, clinics, and through virtual visits. Our services include comprehensive primary care, specialty services, and pharmacy support, tailored to meet diverse patient needs. We collaborate closely with facilities and families to ensure accessible, coordinated, and compassionate care.

Responsibilities

• Facilitate receiving all medical records from the patient’s primary provider and specialists.
• Review medical records.
• Complete consents with patients.
• Enroll patients in Care Management, if they meet eligibility criteria.
• Initiate a Care Management Plan of Care for eligible patients.
• Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
• Complete Annual Wellness Visits (AWVs) to be reviewed by the provider.
• Complete cognitive impairment screenings.
• Complete Social Determinants of Health (SDoH) assessments and/or screenings.
• Complete Advance Care Planning (ACP) documents to be reviewed with the patient by the provider.
• Evaluate for home health, hospice, palliative care, or consults with the Your Health Specialty Division.
• Evaluate for Remote Patient Monitoring (RPM) devices, resources, or tools that may improve the patient’s quality of life.
• Communicate and coordinate care.
• Reconcile prescribed and over-the-counter medications, vitamins, supplements, herbal remedies, and other treatments.
• Provide post-discharge education.
• Evaluate for adaptive equipment and Durable Medical Equipment (DME).
• Evaluate for a safe environment.
• Evaluate acute conditions or follow-up from previous visits.
• Appropriately and accurately document and log Care Management activities.
• Work in conjunction with the care team to keep the patient’s Care Management care plans up to date.
• Coordinate with the patient’s healthcare team, including providers, physical and occupational therapists, home health or hospice representatives, and other individuals in the patient’s care plan.
• Facilitate visits with the appropriate provider or entity.
• Facilitate telehealth visits with a provider for coordination of care, when necessary.
• Coordinate with the patient’s hospice interdisciplinary team and other individuals in the patient's care plan.
• Participate in Interdisciplinary Group (IDG) meetings, when necessary.

Requirements

• Must be a Registered Nurse with a license in good standing with the appropriate board/issuer.
• A minimum of three (3) years of clinical experience is preferred.
• Experience in community settings is preferred.
• Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
• Strong written and verbal communication skills.
• Basic computer knowledge.
• Ability to manage and demonstrate effective leadership skills.
• Good interpersonal and communication skills under all conditions and circumstances.
• Ability to foster a cooperative work environment.
• Team player with the ability to manage multiple responsibilities and demonstrate sound judgment.
• Must be able to work flexible hours and travel between offices, facilities, etc.
• Must be a licensed driver with an automobile that is insured in accordance with state and/or organizational requirements and is in good working order.

Benefits

• Various competitive compensation packages with bonus opportunities.
• Employer-matched 401K.
• Free visit and prescriptive services with a High-Deductible Health Plan (HDHP).
• Employer-matched Health Savings Account (HSA).
• Generous Paid Time Off (PTO) package.
• Career development and growth opportunities.
• Vehicle allowance.