RN - Case Manager

Company: Grace Hospice
Location: Virginia Beach
Posted on: January 8, 2021

Job Description:

RN - Case ManagerU.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.Benefits We Have to Offer:

• Health, Dental, Vision, Disability & Life Insurance
• 401K Retirement Plan
• Paid Holidays
• PTO
• Flexible Spending Account
• Tuition Reimbursement (coming 2021)Position DescriptionUnder the general supervision of the Administrator, the RN - Case Manager provides intermittent skilled nursing services; communicates the patient's 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 Physician's order, admits patients eligible for hospice services
  • Assesses and evaluates patient needs/problems, identifies mutually agreed upon goals with patients
  • Reports patient status and need for other disciplines to Clinical Leadership, attending Physician and Hospice Physician
  • Develops patient care plans 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 documentation and patient care plan submitted to clinical leadership within 2 days following the admit
    • Subsequent patient visit documentation submitted daily
    • Assures that all admit documentation is completed in full at time of submission for timely data entry of IDG/POC information
    • Submits completed skilled nursing notes; communication notes and hospice aide supervisory notes per policy
    • Submits change orders immediately within system
    • Submits recertification paperwork by the due date provided by Clinical Leadership
      • Schedules an IDG meeting with assigned Clinical Leadership to review patient's 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 Clinical Leadership
      • Completes other required documents for recertification: new Medication profile, updates Care Plan, and updates or completes new Hospice Aide Plan of Care, if applicable
      • Participates in discharge planning process
      • Documents Discharge Planning beginning with admit and documents in advance based on agency policy
        • Completes:
          • Patient Care Plan
          • Discharge Nurse's Note and submits them along with other notes turned in per agency policy
          • 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 patient's physician and management as they occur
          • Effectively communicates with all members of the healthcare team
          • Acts as the patient's advocate, and as such, is a liaison to assist in communicating the patient's needs to the multidisciplinary team
          • Provides direction and instruction as it relates to provision of personal care and related support services
            • Completes documentation of hospice aide supervision
            • Reports identified performance related problems; patient complaints and/or deviation from the Hospice Aide care plan to Clinical Leadership
            • At intervals of at least every 14 days, conduct supervisory visits to the patient's home with or without the aide present. More frequent supervisory visits will be necessary when patient care is complicated
            • Ability to perform an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide
            • Acts as a preceptor in 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 CEU's as dictated by the State Board of Nurses
              • Attends skilled nurse in-services and meetings provided by agency
              • Is responsible for obtaining information provided at skill nurse in-services and meetings and demonstrates appropriate follow-up related to information given at meetings and in-services
              • Participates in Quality Assessment and Performance Improvement (QAPI) program through submission of data collection as it relates to direct patient care problems and serving on QAPI teams
                • Responsible for submitting daily occurrence, infection and med-error reports to Clinical Leadership
                • Follows agency policies and procedures to operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations
                • Will understand and apply basic infection control principles and procedures
                • Will contact supervisor with any concerns related to infection control
                • Complete informational visit and obtain patient consents for hospice admission per office procedure
                • Performs other duties as assigned by managementRequired Knowledge, Skills, and Experience
                  • Is currently a registered nurse in the state of practice or in accordance with the Board of Nurse Examiners rules of Nurse Licensure Compact (NLC)
                  • Current driver's license and automobile in good working condition with proof of auto insurance
                  • Is able to meet certain physical demands of standing, bending, lifting, stooping or performing other work requiring light physical exertion (up to 30 pounds) on a continuous basis (over 50% of ttime); or moderate physical exertion (30 to 50 pounds) on a frequent basis (16 to 50% of time); or heavy physical exertion on an occasional basis (up to 15% of time).
                  • 0- 2 years of experience as a Registered Nurse
                  • 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 written and verbal communication skillsPreferred Knowledge, Skills, and Experience
                    • Two years of experience within hospice
                    • Certified Hospice and Palliative Nursing

Keywords: Grace Hospice, Virginia Beach , RN - Case Manager, Healthcare , Virginia Beach, Virginia