Hospice RN Case Manager- Sheboygan Market

Overview

Provide end-of-life care coordination and support for terminally ill patients and families across hospice settings. Service delivery and contact frequency are determined by the Case Manager based on need, with a minimum of every 15 days. Utilize teaching, assessment, and intervention skills to maximize quality of life and comfort for patients and families.

• Identify and coordinate patient/family care across hospice settings; conduct patient and family contacts per case assessment, with a minimum frequency of every 15 days; provide comfort care at end of life and support quality of life through teaching, assessment, and intervention.
• Educate patients and families regarding disease processes, trajectory, disease management, hospice philosophies, signs and symptoms of decline and end of life; update the primary physician as indicated and in accordance with agency, accreditation, state, and federal requirements.
• Review all aspects of each patient on the caseload to ensure appropriate utilization of services and hospice level of care criteria; refer to other team members as appropriate.
• Administer medications and treatments as prescribed by the physician.
• Lead the interdisciplinary care group (IDG) for each patient/family on the caseload; collaborate within the IDG to develop, revise, and implement the patient’s Plan of Care; coordinate services and arrange/evaluate equipment, medical supplies, and other needed items and services.
• Enter, complete, and update documentation in the electronic health record (EHR) per agency/department standards, policies, accreditation, state, and federal guidelines; maintain accurate records of patient experience with assessments and narrative documentation.
• Provide ongoing assessment of patient response to treatments, medications, and teaching; adjust interventions and follow-up as needed; update the Plan of Care (POC) with documented changes; communicate problems and changes in condition to physicians, supervisor, and IDG; enter verbal orders into the EHR as applicable.
• Supervise Home Health Aide and licensed practical nurse visits per agency standards; instruct paraprofessional staff in a timely manner and in compliance with regulations.
• Facilitate discharge planning per agency standards and coordinate with interagency/system and community resources to ensure continuity of care after discharge.
• Wisconsin (WI) only:
  May conduct OASIS assessments for Palliative Care patients and establish/update the plan of care; may conduct hospice initial and comprehensive assessments and ensure continued skilled nursing/home bound criteria are met; initiate preventive and rehabilitative nursing procedures.

• Utilizes proper body mechanics, assistive devices, and safety techniques for patient positioning, repositioning, and transporting; orient and mentor new staff as requested.
• Demonstrates knowledge of age-appropriate care, growth and development, and ability to assess data relevant to patient status and age-specific needs.

• Registered Nurse license issued by the state of practice.
• Basic Life Support (BLS) for Healthcare Providers certification (AHA) required at hire unless exempted by department leadership.
• Driver license issued by the state of Wisconsin or Illinois.

• Completion of an accredited or approved program in Nursing.

• Typically 1–2 years of nursing experience including home health, hospice, medical/surgical, long-term care, emergency care/ICU, oncology, or related areas.

• Competence in deformation prevention, normal range of motion, body mechanics, and body alignment; understanding of basic human behavior and the effects of stress on individuals and groups.
• Excellent awareness, perception, and communication skills; strong interpersonal abilities.
• Excellent decision-making and critical-thinking skills; ability to work independently and make sound judgments.
• Excellent prioritization and organizational skills.
• Valid Driver License and access to a registered, insured vehicle.

• Lift up to 50 lbs from floor to waist; lift up to 20 lbs overhead; carry up to 40 lbs a reasonable distance.
• Push/pull with at least 30 lbs of force; perform sliding transfers with assistance.
• Ability to work safely with individuals of varying sizes and medical conditions; move in confined spaces; perform bending, kneeling, squatting, and occasional overhead reaching.
• Exposure to mechanical, electrical, chemical hazards and to blood and body fluids; use protective clothing and equipment as needed.
• Functional speech, vision, hearing, and touch; fine motor skills; operate necessary equipment.
• This job description reflects the general nature and level of work; other related duties may be assigned.