RN Case Manager

4 weeks ago

Milledgeville, United States Primecare Home Care Services Full time $70,000 - $80,000
Job DescriptionJob DescriptionABOUT PRIMECARE HOSPICE & PALLIATIVE CARE:


At Primecare Hospice, caring is not just our duty; it's our purpose. We are a patient-centered, physician-led, and team-based holistic hospice program. We understand the profound importance of every moment in a person's life, especially during their hospice journey. That's why we are dedicated to making every moment matter. Our team of compassionate professionals is here to support and care for our patients and their families with empathy, respect, and unwavering commitment. We believe that in the midst of life's most challenging moments, there is an opportunity to provide comfort, dignity, and a sense of peace. At Primecare Hospice, we are honored to be a part of this journey and to make each moment as meaningful as possible.

Hospice is primarily a home care program, but services may also be provided in a hospital or nursing home. The hospice team, called the interdisciplinary group (IDG), helps you and your family make informed decisions about caregiving, teaches skills for care and helps with end-of-life care. Hospice also offers help through the bereavement period.

Position Summary:
To plan, coordinate and provide hospice care in accordance with the patient's plan of care.

Essential Duties:
  • Coordinates hospice care by working with other team members as well as with the patients/family members to ensure needs are met.
  • Evaluate the effectiveness of hospice services to the patient and family on an ongoing basis.
  • Perform evaluations for hospice care along with informational visits as needed.
  • Utilize the nursing process to provide professional nursing care.
  • Consult with the attending physician and Hospice Medical Director concerning changes in patients condition requiring order changes and/or changes in the plan of care.
  • Coordinate patient services with other members of the IDG as well as contracted services, when needed.
  • Submit complete, accurate and relevant clinical notes in a timely manner.
  • Submit patient visit schedule weekly.
  • Participate in IDG and case conferences.
  • Discuss with the supervisor if IDG determines that the patient would benefit from contracted services.
  • Take responsibility for ensuring patients plans of care are kept current.
  • Performs on-call duties (including holidays) per policy and agency need.
  • Actively participates in QAPI meetings and activities.
  • Participate in staff development meetings.
  • Continually strive to improve his/her nursing care skills by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations and/or individual research and reading.
  • Provide education to patients/family members regarding the dying process, plan of care and offer guidance with healthcare decisions.
  • Provide dietary counseling, taking into account health issues and dietary changes at the end of life.
  • Perform death visit per agencys policy.
  • Participate in the patients discharge planning process.
  • Maintain an on-going knowledge of current drug therapy.
  • Adhere to Federal, state and accreditation requirements including Medicare and Medicaid regulations.
  • May be requested by a supervisor to fill in for the other nurses.
  • Conduct an initial as well as ongoing comprehensive assessments of the patients.
  • Obtain a medical history from the patient and/or a family member particularly as it relates to the present condition.
  • Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite, and type of diet, etc.
  • Evaluate the patient, family member(s) and home situation to determine what health teaching will be required.
  • Evaluate the patient's environment to determine what assistance will be available from family members in caring for the patient and what services may be needed.
  • Be competent in knowledge about different levels of care and when its appropriate to offer them.
  • Explain nursing and other Agency services to patients and families as a part of planning for care.
  • Develop and implement the initial plan of care and work with other members of the IDG in completing and maintaining the comprehensive plan of care.
  • Nursing services, treatments and preventative procedures requiring substantial specialized skill and ordered by the physician.
  • Observing signs and symptoms and reporting to the physician reactions to treatments, including drugs, as well as changes in the patient's physical or emotional condition.
  • Supervise and evaluate the care given by the Hospice Aide at a minimum of once every 14 days and as needed.
  • Chart those services rendered to the patient by the staff nurse and changes that have been noted in the patient's condition and/or family and home situation, makes revisions in the nursing care plan as needed, records supervisory visits conducted with the Hospice Aide, evaluates patient care and progress, and closes charts of discharged patients.
  • Evaluate the effectiveness of her nursing service to the individual and family.
  • Discuss with the supervisor problems concerning the patients and possible resolution.
  • Provide guidance and supervision to the LPN and supervises the LPN a minimum of every 30 days.
  • Cooperate with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan.
  • Participate in staff development meetings.
  • Prepare the care plan for the Hospice Aide.

Job Conditions
  • Position may be stressful.
  • The ability to access patients homes which may not be routinely wheelchair accessible is required.
  • Hearing, eyesight, and physical dexterity must be sufficient to perform a physical assessment of the patient's condition and to perform and demonstrate patient care.
  • Physical activities will include, walking, sitting, stooping, and standing and minimal to maximum lifting of patients and the turning of patients.


Required Knowledge, Skills, Abilities and Competences:
  • Available to be on call.
  • Ability to demonstrate self-confidence and positive attitude toward self and others and maintain commitment and enthusiasm to goal achievement.
  • Ability to identify and evaluate personal strengths and weaknesses of self and others.
  • Has knowledge of applicable local, state, and federal laws.
  • Must have excellent assessment skills and problem-solving skills.
  • Must be a licensed driver with an insured automobile in good working order.
  • Knowledge and understanding of spreadsheets.
  • Excellent written and verbal communication skills.
  • Excellent organizational and time management skills.
  • Ability to exercise discretion and professionalism when overseeing highly confidential and sensitive information.

Qualifications:
  • Must be a graduate from an accredited School of Nursing.
  • Must be a Registered Nurse who is currently licensed to practice nursing under the provisions of Article 1 of Chapter 26 of Title 43 of the Official code of Georgia.
  • One year of RN experience. Hospice experience preferred.
  • CPR certified to care for patients without DNRs
  • Must have excellent assessment skills and problem-solving skills.
  • Should be skillful in organization and in the principles of time management and have knowledge of case management processes.
  • Must be a licensed driver with an insured automobile in good working order.
  • The ability to communicate well, both verbally and in writing.
  • Must have no exceptions to RN license, and be able to administer pharmaceuticals, perform medication reconciliation, and any nursing procedures or special treatments needed within the scope of nursing practice for the state.
  • All skills to be competencies before actual hands-on patient care, and when procedures or treatments are not usually performed.

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