RN Case Manager- Facility Team (HPH Hospice)

About the Role

The RN, Case Manager is responsible for assessing and identifying patient/family needs, utilizing the nursing process, coordinating the Plan of Care with the Interdisciplinary Team (IDT), and providing clinical, palliative, and supportive care to the patient/family unit to keep the participant in their home environment as long as possible.

Responsibilities

• Provides and manages direct care to patients and families as part of the Interdisciplinary Team (IDT), incorporating psychosocial, spiritual, cultural, physical, and biological components.
• Coordinates the Plan of Care, ensuring an individualized Plan of Care is developed that reflects the patient’s evolving needs.
• Educates patients, families, caregivers, and other health professionals about disease processes, prevention, palliative interventions, caregiving, the dying process, and safety practices.
• Conducts home visits to assess home safety, medication compliance, nutritional compliance, DME compliance, and ability to live safely in the community.
• Reports changes in the patient’s condition to appropriate members of the IDT or other health professionals.
• Participates with the IDT to evaluate hospice referrals/admissions for level of care appropriateness.
• Attends daily IDT collaboration meetings and presents concise, pertinent oral and written reports.
• Communicates accurately and completely with physicians, staff, patients, families, and supervisors; utilizes positive approaches when working with others.
• Supervises patient care provided by Community Health Workers and Home Health Aides as requested.
• Provides reassurance and solutions to patients and families via phone, coordinates in-person visits when needed, and documents interactions in the EMR.
• Utilizes appropriate support resources to resolve complex situations and communicates with the IDT.
• Completes initial and semi-annual assessments, explains services to patients/families, and initiates skilled nursing interventions.
• Obtains physician orders and completes documentation per Company policy.
• Acts as the Company representative at assigned facilities, facilitating referrals to all service lines.
• Develops strong relationships with case managers, physicians, and other facility staff.
• During emergencies (e.g., hurricanes), may be required to report to a designated location to ensure continuity of services.
• Performs other duties as assigned.

Requirements

• Current RN license in the state of employment.
• Minimum of one (1) year nursing experience; hospice or hospital experience preferred.
• Certification of completion of Alzheimer’s Disease and Related Dementias Training (for employees working at PACE).
• Previous experience with an EMR/EHR system.
• Valid driver’s license, automobile insurance, and reliable transportation to meet visit schedules.
• Ability to use equipment with visual and auditory mechanisms.
• Effective communication in English (verbal and written).
• Ability to perform home visits and assessments.
• Ability to perform essential physical functions (lifting patients/equipment, bending, pushing/pulling, kneeling) with or without reasonable accommodation.
• Active BLS certification for healthcare professionals from the American Heart Association or Red Cross.

Competencies

• Satisfactorily complete competency requirements for this position.

Responsibilities of All Employees

• Represent the Company professionally through care and services provided.
• Comply with all State, federal, and local regulations, maintaining a strong position against fraud and abuse.
• Adhere to Company policies, procedures, and standard practices.
• Observe health, safety, and security practices.
• Maintain confidentiality of patients, families, colleagues, and sensitive situations.
• Use resources in a fiscally responsible manner.
• Promote the Company through community and professional organizations.
• Participate in improving performance at organizational, departmental, and individual levels.
• Improve professional knowledge and skills, including electronic media proficiency.
• Support Company research and educational activities.
• Share expertise with co-workers formally and informally.
• Participate in Quality Assessment and Performance Improvement activities as appropriate.

Physical Demands

The following abilities are required for this role, with or without reasonable accommodation:

• See, hear, talk, walk, and use hands to finger, handle, or feel.
• Frequently stand, sit, reach with hands/arms, lift, bend, and balance.
• Occasionally pull, push, stoop/crouch, kneel, and climb stairs.

Pay

Pay Range: $61,860.66 – $96,657.28