RN Case Manager

RN Case Manager

U.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

Position Description

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
• Assess 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 plan 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 the 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 skilled 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
• Preforms other duties as assigned by management

REQUIRED Knowledge, Skills and Experience

• Is currently a registered nurse in the state of practice or in accordance with the Board of Nurse Examiners rules for Nurse Licensure Compact (NLC)
• Must maintain a valid driver’s license and good driving record
• 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 time); 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)
• 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 skills

Preferred Knowledge, Skills and Experience

• Two years’ experience within hospice
• Certified Hospice and Palliative Nursing

Additional Florida Requirements

• Active CPR Certification