Rn Iii Case Manager

RN III Case Manager

Why work with us?
As part of an IDT Team, you will be working with a diverse group of individuals who are dedicated to delivering the highest quality hospice care while being deeply committed to giving back to the community.
Reporting to the Team Manager, the Registered Nurse (RN) Case Manager is responsible for identifying the patient’s and family’s physical, psychosocial, environmental, safety and developmental needs and individualizing the patient’s plan of care based on the needs identified.
The RN Case Manager coordinates patient/family care and ensures continuous assessment of each patient and family’s needs and implementation of the plan of care under the direction of the attending physician and Medical Director/Hospice physician in conjunction with the interdisciplinary team. Hospice nursing services are based on the initial and ongoing assessment of the patient's needs and are provided in accordance with the interdisciplinary team's care plan. Each Case Manager triages and coordinates the care of up to 15 patients with the assistance from Revisit Nurses and in collaboration with the Team Manager.
ESSENTIAL FUNCTIONS
Identify and address signs of actively dying.
Communicating and collaborating with patient care, MSW and SCC
Hospice nursing services include:
Assessing all aspects of the patient’s pain and developing an individualized pain management plan.
Anticipating, preventing, and treating undesirable symptoms or secondary symptoms
Identifying and addressing comfort care needs.
Supporting, instructing, and educating the patient, family and caregiver using teach back.
Documenting problems, nursing assessments, appropriate goals, care provided, care interventions and patient and family outcomes achieved from intervention and care provided.
Maintaining the dignity, confidentiality and privacy of the dying patient.
Supporting the patient’s unique spiritual and cultural beliefs.
Providing holistic, family-centered care across treatment settings to improve the quality of life.
Consulting and collaborating with the interdisciplinary team and others involved in the patient’s care.
Coordinating patient care plan with After Hours and Crisis Care Staff.
Attend, document, and present appropriate patient-related information at the Interdisciplinary Team Meetings utilizing the IDT templates.
Updating the comprehensive assessment and patient’s progress towards desired outcomes at least every 15 days.
Completing patient-related documentation within 2 hours of the shift worked.
Adhering to and complies with state and federal regulations, as well as accreditation standards.
Providing patient and primary caregiver education/training, as appropriate, for care and services identified in the plan of care.
Adhering to evidence-based standards of practice that are endorsed by the agency.
Identify and address signs of transitioning
Coordinate care for transfers to GIP level of care
Coordinate care with Ahf, RCFE, & SNF
Other Case Management responsibilities:
Communicating with Team Manager as appropriate regarding patient acuity, scheduling, workload, and difficult situations.
Following the agency’s process for effective “hand off” communication.
Participating in educating new staff members as assigned by the Team Manager.
Supervising performance of LVN and Home Health Aide.
Attending appropriate in-services held for Hospice of the East Bay staff.
Initiating and ongoing monitoring of medication reconciliation processes according to Medicare and accreditation standards.
Work with passionate team members that have the same commitment to our organization as you.
Fun and exciting environment
403b Retirement Account and generous company match.
Medical, Vision, and dental; some plans qualify for a Health Saving Account (HSA)
Up to 27 days of PTO/Holiday
Group & Voluntary Life / Accidental Death & Dismemberment Insurance
Tuition Reimbursement
Employee Discounts
Employee Assistance Program
Come join us as we are a certified "Best Place to Work" for the past four years in a row!