Hospice RN Nurse Case Manager

We are seeking a Registered Nurse to service our patients throughout the Gainesville area. This role is a critical part of the patient’s care team, visiting patients and facilitating care with appropriate providers.

About

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 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, if the patient is eligible.
• Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
• Complete Annual Wellness Visits (AWV’s) 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’s) to be reviewed with the patient by the provider.
• Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
• Evaluate for RPM devices, resources, or tools that may improve the patient’s quality of life.
• Communicate and coordinate care.
• Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments.
• Provide post-discharge education.
• Evaluate for adaptive equipment and Durable Medical Equipment (DME).
• Evaluate for safe environment.
• Evaluation of acute condition(s) or follow-up from previous visit.
• Appropriately and accurately document and log Care Management activities.
• Work in conjunction with care team to keep the patients Care Management care plans up to date.
• Coordinate with the patient’s health care team, providers, physical and occupational therapists, home health or hospice representatives, and other individuals in the patient’s care plan.
• Facilitate visits with appropriate provider or entity.
• Facilitate a telehealth visit 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 clinical experience preferred.
• Experience in community settings preferred.
• Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
• Strong written and verbal 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 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.
• Reliable transportation is required as travel is required daily.

Benefits

• Various competitive compensation package with bonus opportunities.
• Employer-matched 401K.
• Free visit and prescriptive services with HDHP Insurance Plan.
• Employer-matched HSA.
• Generous PTO package.
• Career development and growth opportunities.
• Vehicle allowance.

Schedule

This is a full-time, salary-based position.

Service areas currently available: Gainesville, GA; Monroe, GA; Watkinsville, GA; Athens, GA.