Registered Nurse

Position: RN Case Manager — Hospice/ALF

Department: Nursing

Reports to: Hospice Director, Wellness Director, ALF Administrator or Director

Position Overview - The RN Case Manager (CM) is a Registered Nurse who is responsible for the assessment, planning, coordination, provision and documentation of care for assigned patients. The CM interacts effectively with patients, significant others, and other team members while maintaining standards of professional nursing and clinical competency. The CM develops and implements a hospice plan of care (POC) in conjunction with the Inter-Disciplinary Group (IDG) that meets each patient's specific needs and is in compliance with all relevant federal and state regulations, as well as the Center's policies and procedures.

The CM provides care and performs other appropriate duties as assigned in a variety of physical settings including, but not limited to: patients' homes; nursing homes; assisted living facilities; and, the Center's residential centers.

CM's are routinely assigned to multiple locations during a standard shift. CM's must be able and willing to travel as needed and to perform functions appropriate to the setting.

Essential Functions & Responsibilities:

1. Assesses patients' clinical status and environment to identify needs for treatment and personal care to address pain and other discomforting effects of the primary and related illnesses and conditions;
2. Ensures that patient care needs are being met as identified in the initial, comprehensive and ongoing assessments of the patient's physical, emotional, psychological, spiritual and environmental conditions;
3. Responsible for identifying, coordinating, and providing patient/family care to patients and families in their own home, skilled nursing facility or residential care facility (including the Center's unique residences);
4. Participates in triage system of phone calls and performs, or assigns care to home patients as needed and to residential patients in accordance with their needs;
5. Provides education/counseling/interventions necessary to provide comfort care and maximize the quality of life for the patient and family;
6. Develops, evaluated and revises a written POC in conjunction with IDG members that meets the needs of the patient and their immediate family/caregivers; Participates in regularly scheduled IDG meetings;
7. Develops Home Health Aide (CHHA) POC in accordance with patient's assessed needs and revises CHHA POC as changes in patient's needs occur. Supervises CHHA service at least once every 2 weeks;
8. Orients assigned CHHA to POC when initially assigned and upon any necessary changes;
9. Establishes nursing visit frequency to patients based on assessment of needs, but with a minimum of once a week in compliance with agency policy (See also: Nursing Visit Frequency Policy);

10. Maintains skills to meet patients' needs for nursing care to patients as prescribed by the physician and in the Interdisciplinary Group, including but not limited to: monitoring/tracking of Vital Signs, IV placement, comprehensive personal care, phlebotomy, medication administration and wound care;
11. Authorizes, coordinates and supervises care of subordinate care providers, as prescribed in the Interdisciplinary Plan of Care, and in accordance with state, and federal regulations when using ancillary personnel, i.e.-Licensed Practical Nurses as well as Certified Home Health Aids, in order to meet the needs of the patient;
12. Documents accurate and ongoing patient assessments and care. Maintains up-to-date patient charts of patient care and regular communication with the patient's physician, family and IDG members. Documentation is entered accurately and timely into the Electronic Medical Record (EMR). (See also: Documentation Policy);
13. Obtains and implements all necessary physician orders and collaborates with the patient's primary physician as well as hospice medical director as the patient's needs dictate;
14. Initiates needed referrals to other disciplines and/or community resources;
15. Supervises and maintains ongoing effective communication with other hospice personnel involved with patient care. This may involve formal and informal team meetings;
16. Provides bereavement support to the family as appropriate;
17. Ensures medications and controlled substances are ordered, received, administered, documented, stored and disposed of in accordance with state regulations and residence policies and procedures;
18. Assumes responsibility for personal growth and development while maintaining and upgrading professional knowledge and practice skills through attendance and participation in continuing education and in-service classes. Completes all mandatory education as per agency policy:
19. Fulfills the obligation of requested and/or accepted case assignments;
20. Actively participates in the Quality Assessment and Improvement Program;
21. Performs other duties as assigned consistent with skills and training and the Center's mission and goals.

Qualifications & Education Required:

1. Graduate of an accredited school of professional (registered) nursing;
2. Currently licensed as an RN through the NJ State Board of Nursing;
3. Medical/Surgical and/or other experience to demonstrate basic, safe nursing knowledge and skills;
4. Complies with accepted professional standards and principles;
5. Flexible and available for assignments to varied days, venues and shifts;
6. Requires advanced time management and organizational skills, strong interpersonal relationship skills; and, must be supportive of organizational policies and philosophy;
7. Demonstrates physical/mental ability to perform job function. Presents a pre-employment physician's health clearance as defined by the agency's policy. This position requires the ability to carry up to 25 pounds and push and pull up to 50 pounds. Occasional climbing, stooping, kneeling, reaching and fingering are required. Exchanging ideas by means of the spoken and written word, primarily in English is required. Must be able to hear and distinguish sounds, see and focus on shape, size, distance, motions, depth, color and other characteristics in day or nighttime. The job requires frequent sitting, standing and walking. The job requires work both inside and outside the agency's building. Must be able to enter buildings and homes that are not handicap accessible. Must be able to perform basic arithmetic operations quickly and accurately and be able to problem solve, reason and analyze. Able to drive, walk, climb, bend, reach and lift as needed to travel to, and provide assigned patient care, unaided, in un-controlled environments;