RN Case Manager

Responsibilities: 1. Provide case management to patients as assigned by the supervisor. During staffing shortages may be required to manage extra cases on a short term basis. 2. As assigned, assess a patient’s needs and admission for service in required time frame. 3. Work with the Interdisciplinary Group (IDG or IDT) to develop a plan of care (POC). Attend IDT meetings to provide information regarding the patient’s POC. 4. Re-evaluate the patient’s nursing needs on a regular basis and update plan of care according to hospice policy for patient’s physician’s approval. 5. Implement the POC. 6. Obtain physician orders when necessary. Document verbal orders within 24 hours in the medical record and ensure that orders are countersigned by the health professional initiating the order within 15 working days of receipt. 7. Provide services requiring substantial and specialized nursing skill, such as IV administration, wound care, and physical assessment. 8. Educate the patient and patient’s family in the care of the patient, including pain management. Instruct family members/caregivers regarding routine patient care, i.e., administration of medication, bathing, feeding, dressing changes, etc. Encourage family to participate in patient’s care, empowering them when possible so that their ability to provide care increases to their capability. 9. Evaluate the outcome of services and make changes in the POC as necessary. 10. Coordinate and communicate the patient’s physical or medical condition to the IDT. 11. Prepare clinical notes according to policy, including within appropriate time frames. Complete up-to-date charting and other record keeping according to hospice policy. Write nursing progress note on day of visit. 12. Supervise licensed practical nurses (LPNs) and home attendants (hospice aides or HAs) providing delegated nursing services. Make visits to the patient’s home as frequently as necessary but not less than every two weeks. Document the results of each visit in the medical record. (12 VAC 5-391-350.D) Assure that HA is present in the home and delivery services during the supervisory visit per policy. 13. Make regular visits to patients in order to evaluate pain and symptom control and to assess other patient/family needs. 14. Provide emotional support for patients/families. 15. Record name and frequency of visits on IDG Member List in the hospice information guide and ensure that form is kept in the patient’s home and updated as needed. 16. Report changes in the patient’s medical or mental condition to the attending physician and to hospice employees and contractors involved in the patient’s care. 17. Develop HA plan of care and communicate it to HA and supervisor. 18. Place report according to department procedure each working day. 19. Request vacation and give report on all patients in caseload prior to vacation according to departmental procedure. 20. Attend and participate in IDT meetings, department meetings, patient care meetings, staff meetings, and other meetings as directed by supervisor. 21. Participate in mandatory in-services and continuing education annually. 22. Review report from on-call nurse by 8:30am 23. Participate in orientation of new nursing/other GSH staff at direction of the supervisor or Nurse Preceptor. 24. Participate in taking nursing students on pre-arranged visits at the direction of the supervisor. 25. Assist with chart reviews, quality assurance reviews, and evaluation of the nursing services as requested. 26. Fulfill responsibilities of on-call nurse at times designated by the supervisor. 27. Supervise and deliver IV therapy services according to current policy, including all education and training requirements. 28. Carry out other duties as assigned by the supervisor. Qualifications: 1. Graduate from an accredited school of nursing, 2. Currently licensed to practice nursing by the Virginia State Board of Nursing, 3. Prefer at least two years’ experience in acute care, ho