The RN Case Manager is a member of the interdisciplinary team and serves as the pivotal clinician in identifying the physical, psychological, social, and spiritual needs of hospice patients and their families. This role is responsible for conducting admissions, initiating appropriate interventions and support upon referral, and providing a continuously appropriate, comprehensive, and responsive plan of care.
The RN Case Manager coordinates hospice services, ensures regulatory compliance, and supports a seamless transition into hospice care while maintaining the highest level of comfort and quality of life for patients and families.
Duties and responsibilities
Admissions and Initial Assessments:
1. Coordinate and respond to referrals promptly (accept referrals within 15 minutes when applicable).
2. Complete admission visits timely and in accordance with agency standards.
3. Conduct comprehensive initial assessments including physical, psychosocial, emotional, spiritual, social, economic, and cultural factors that influence care.
4. Determine hospice eligibility in accordance with Medicare/Medicaid and regulatory guidelines.
5. Obtain, review, and process physician orders, medical records, and required documentation to support admission.
6. Educate patients and families on hospice philosophy, services, benefits, and expectations.
7. Initiate the Interdisciplinary Plan of Care in collaboration with the hospice team.
8. Coordinate durable medical equipment (DME), medications, and other necessary services upon admission.
9. Complete and submit all admission documentation accurately and within required timeframes.
10. Close visits same day in the electronic medical record (EMR).
Case Management & Ongoing Care
1. Assume primary responsibility for case management of assigned patients in homes, skilled nursing facilities, or residential care facilities.
2. Provide a minimum of one visit per week, with frequency determined by patient need and clinical assessment.
3. Provide direct nursing care as prescribed in the Interdisciplinary Plan of Care to maintain comfort and quality of life.
4. Perform ongoing assessments and revise the Plan of Care weekly or as patient condition changes.
5. Supervise and provide clinical oversight to assigned nursing assistants and licensed practical nurses.
6. Authorize, coordinate, and supervise care provided by vendors and external providers.
7. Maintain effective communication with physicians, referral sources, and interdisciplinary team members.
8. Attend and actively participate in Interdisciplinary Team (IDT) meetings.
9. Maintain compliance with visit structure and agency standards.
10. Complete documentation at point of care, ensuring accuracy, timeliness, and regulatory compliance.
11. Maintain up-to-date patient records and ensure visits are closed on time.
12. Participate in on-call rotation as needed.
13. Handle patient information calls and assist with triage overflow when necessary.
14. Provide emotional support and education to patients and families regarding symptom management, disease progression, and end-of-life planning.
15. Assist with advance care planning discussions, including advance directives and goals of care.
16. Advocate for patient needs and ensure families understand hospice resources and benefits.
17. Adhere to all federal, state, and local hospice regulations and agency policies.
18. Maintain current knowledge of hospice and palliative care best practices.
19. Perform other duties as assigned consistent with skills, training, and agency mission.
Qualifications
1. Graduate of an accredited school of nursing.
2. Valid license as a Registered Nurse in the State of Colorado
3. Home Health and/or hospice experience highly desirable
4. Current Basic Life Support Certification
5. Valid Colorado Driver’s License with no more than 3 moving violations in the last 36 months.
6. Valid automobile insurance that meets minimum state law coverage limits
7. Able to cope with emotional stress and be tolerant of individual lifestyles.
8. Sensitive to the needs of terminally ill patients and families and one’s own feelings about dying and death.
9. Basic computer skills
10. Ability to provide an annual TB test.
11. Ability to obtain an annual influenza vaccine or provide a certified medical contraindication form.
Physical requirements
1. Intermittent physical activity includes walking, standing, sitting, lifting, and supporting patients.
2. Must be able to lift/carry, push/pull up to 100 lbs.
3. RN may be exposed to viruses, disease and infection from patients and specimens in the working environment.
4. RN will be required to work at patient’s homes or in the facility where the patient resides and is responsible for own transportation.
5. May experience traumatic situations in the family setting.
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