RN Case Manager
U.S. Medical Management (USMM) is an affiliate of a leading Fortune 100 company. A national organization built on a continuum of care with premier healthcare providers, clinicians and patient focused individuals working together. Our Mission Through Compassionate Patient-Centered Care in the Home; We will Provide Exceptional Outcomes across our Continuum of Services Visiting Physicians Association, Pinnacle Senior Care, Grace Hospice, Comfort Hospice, Home DME & our In Home Health Assessments (IHA).
Our Values of Integrity, Respect, Teamwork & Excellence are leading us to a better tomorrow for patient care. Our Purposes Centered on We are Unified in our Work through our Continuum of Services We can Find Comfort that We are Making a Difference for our Patients & We make a Broader Positive Impact on Society, allows USMM to be poised for a phenomenal future.
We are seeking candidates who desire the experience of delivering quality & compassionate healthcare within proven care models with patients at the forefront of everything we do.
Some of the benefits and advantages of working with Grace Hospice Include:
- Grace Hospice is CHAP accredited and we are Members of the National Hospice and Palliative Care Organization.
- We invest in our employees career development and growth.
- Comprehensive orientation programs for new hires
- Leadership Academy meetings held off-site regularly for continuous development of our site leadership team members (Office Manager, CS, DCS, and Administrator).
- Grace offers advancement opportunities.
- Grace Hospice has 25locations across the U.S. and we are growing! This growth creates additional advancement opportunities for strong performers.
- We provide an innovative healthcare environment offering a clinical ladder.
- Grace is founded firmly on five pillars of excellence: People, Service, Quality, Finance, and Growth.
- Our environment offers collaboration and provides tools and programs to enhance our teams ability to provide excellent care.
- Our point-of-care system is state of the art: HomeCare HomeBase.
- Employees have access to referring physicians and other professional resources on a daily basis.
- Inter-disciplinary Team conferences are held regularly to discuss and optimize patient care.
- Our Meaningful Memories program is in development to provide exceptional patient experiences.
Under the general supervision of the Administrator, the RN-Case Manager provides intermittent skilled nursing services; communicates the patients progress with other disciplines and directs, supervises and instructs nonprofessional hospice aide staff in the provision of personal care to the patient.
Essential Duties and Responsibilities
- Under the Physicians order, admits patients eligible for hospice services
- Assess and evaluates patient needs/problems, identifies mutually agreed upon goals with patients
- Reports patient status and need for other disciplines to agency intake coordinator, RN Manager and referring Physician
- Develops patient care plan that specifically addresses identified patient problems; nursing problems and goals. Updates care plans on an ongoing basis; revises and resolves patient problems and goals as changes occur and/or recertification
- Admit paperwork and patient care plan submitted to RN Manager within 2 days following the admit
- Assures that all admit paperwork is completed in full at time of submission for timely data entry of IDG/POC information
- Provides intermittent Skilled Nursing services including assessment, evaluation, procedures, teaching and training activities as outlined in the patient IDG Plan of Care
- Provides Skilled Nursing visits according to visit schedule and notifies agency of need to alter schedule in any way
- Reports significant findings to patients Physician and RN Manager as they occur
- Submits completed skilled nursing notes; communication notes and hospice aide supervisory notes per policy
- Submits change orders within 48 hours of occurrence
- Submits recertification paperwork by the due date provided by the RN Manager
- Schedules an IDT meeting with assigned RN Manager to review patients needs, problems, level of care and any changes in Plan of Care for next cert period
- Completes communication note documenting plans for recertification were discussed and agreed upon between the physician, patient, and RN Manager
- Completes other required documents for recertification: new Medication Profile, updates Care Plan, and updates or completes new Hospice Aide Plan of Care, if applicable
- Performs hospice aide supervisory visit at least q 2 weeks, and annually with hospice aide present
- Effectively communicates with all members of the healthcare team
- Acts as the patients advocate, and, as such, is a liaison to assist in communicating the patients needs to the multidisciplinary team
- Supervises the hospice aide every 14 days
- Provides direction and instruction as it relates to provision of personal care and related support services
- Completes documentation on hospice aide supervisory notes
- Reports identified performance related problems; patient complaints and/or deviation from the Hospice Aide instruction sheet to the RN Manage
- Acts as a preceptor in the orientation of new nursing staff
- Attends staff meetings and educational in-services per agency requirements
- Continually strives to improve nursing care by broadening knowledge through formal education, attendance at workshops, conferences and participation in professional and related organizations and individual research reading
- Obtains CEUs as dictated by the State Board of Nurses
- Attends at least 50% of the skilled nurse in-services and meetings provided by agency
- Is responsible for obtaining information provided at skilled nurse in-services and meetings and demonstrates appropriate follow-up related to information given at meetings and in-services
- Participates in PI program through submission of data collection as it relates to direct patient care problems and serving on PI teams
- Follows agency policies and procedures
- Participates in discharge planning process
- Documents Discharge Planning beginning with admit and documents at least 2 weeks in advance instructions given related to discharge
- Patient Care Plan
- Discharge Nurses Note and submits them along with other notes turned in per agency policy
REQUIRED Knowledge, Skills and Experience
- Is currently a Registered Nurse in the state of practice or in accordance with the Board of Nurse Examiners rules for Nurse Licensure Compact (NLC)
- Current Drivers License and automobile in good working condition with proof of auto insurance
- Ability to work in a field setting and exhibited ability to make sound nursing judgments
- Ability to assess patient needs and formulate individualized patient care plans to meet those needs
- Effective communication skills
- Must have and maintain an automobile to be used for work
Preferred Knowledge, Skills and Experience
- One year experience as a professional nurse
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