Reports to the Manager. Responsible for Case Managing assigned Homecare and Hospice patients. Responsible for assisting in meeting the standards and conditions of participation for MDPH certification and Joint Commission accreditation, and other regulations that may apply. This position is an intricate part of the Home Health and Hospice department and the Hospice •Interdisciplinary Team•. Assists with maintaining the standards, policies and programs that are consistent with the organization's mission, vision, goals, and objectives. Performs within the prescribed limits of the hospital's/department's Compliance Program. Responsible to detect, observe and report compliance variances to their immediate supervisor, or, upward through the •chain of command•, Compliance Officer or hospital hot-line.

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

• Completes nursing assessments on admission and through discharge.
• Responds in a timely fashion to referrals for RN case manager intervention.
• Meets with patients/families/significant other and develops in home plan of care.
• Documents patient assessment promptly and completely.
• Works with patient and family to provide necessary education and facilitation of linkages with community services and resources.
• Provide information for support, advocacy and rights as needed for patient and family.
• Provides/refers for financial counseling as appropriate.

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

• The knowledge, skills, and abilities as indicated below are normally acquired through the successful completion of nursing program from an accredited school of nursing with a current Michigan license to practice as a Registered Nurse. Four (4) years Home Health and Hospice experience preferred. Knowledge of regulations affecting home health care and/or hospice.

• Possesses outstanding interpersonal skills with focus on listening, assertion, conflict resolution and collaboration.
• Provides oversight of plan of care and discharge readiness.
• Identify psychosocial issues and collaborate with other team members.
• Possesses strong knowledge of medical and clinical processes. Develops clinical expertise appropriate for designated patient population.
• Provides ongoing focus for clinically and socially complex patients.
• Works with patient's families and other members of the healthcare team to assist in navigating the complicated service systems.
• Understands function of complex healthcare organization providing broad scope of services.
• Ability to communicate positively and effectively with all levels of participants in health care delivery in both formal and informal settings and with individuals as well as groups of varying size and through documentation.
• Verify and obtain mandatory Medicare notices.
• Capable of managing complex workload and establishing priorities.
• Maintains up-to-date knowledge of reimbursement processes and community resources.

• Complexity of workload and communications may involve mental stress.
• Has an assigned rotation for on-call and holiday rotation.
• Will be expected to perform job duties within the home environment.
• Possible exposure to communicable disease and unsanitary conditions in the home.
• Will be required to drive an automobile in all types of weather.

• Requires the physical ability and stamina (i.e., to walk/stand for prolonged periods of time, push carts/wheelchairs up to 50 pounds, to position/lift patients at a maximum of 35 pounds unassisted, over 35 pounds requires assistance, provide CPR, etc.) to perform the essential functions of the position.