Job Title/Position: Hospice Nurse Case Manager

Reports To:              Director of Nursing

FLSA Status:             Exempt

Job Description Summary

The Hospice Nurse Case Manager plans and delivers care to patients utilizing the nursing process of assessment, planning, interventions, implementation, and evaluation; and effectively interacts with patients, significant others, and other interdisciplinary team members while maintaining standards of professional nursing and clinical competency.

Essential Job Functions/Responsibilities
  1. Operates under the director of the Director of Nursing and under the Medical Director’s orders.
  2. Responsible for identifying and coordinating patient/family care to support terminally ill patients and families in home, skilled nursing facility or residential care facility. Frequency of patient / family contacts will be at the discretion of the Case Manager and his/her assessment of need, but will be a minimum of once per week. The Case Manager endeavors to utilize teaching, assessment, and intervention skills to provide comfort care and maximize the quality of life for the patients and families.
  3. Depending on the acuity of the patient, the Case Manager is expected to make 4-5 visits per day with documentation. Case load is approximately 10-12 patients for 40 hrs/week 8-10 patients for 32 hrs/week, 6-8 patients for 24 hrs/week and 4-6 patients for 20 hrs/week.
  4. Assess home care needs, being aware of the physical, emotional, and spiritual aspects and gather data on social, economic and cultural factors which may influence health, well-being and quality of life.
  5. Assist patients, family members or other clients with concern and empathy; respect confidentially and privacy and communicate in a courteous and respectful manner.
  6. Provide direct care to patients as prescribed in the Interdisciplinary Plan of Care in order to maintain the highest level of comfort and quality of life and assuming primary responsibility for case management.
  7. Evaluate and perform ongoing assessment and revise initial written plan of care with Interdisciplinary collaboration weekly or as the needs and conditions of the patient/family change.
  8. Authorize, coordinate and supervise care, as prescribed in the Interdisciplinary Plan of Care, with contracted vendors in order to meet the needs of the patient.
  9. Attend and participate in weekly patient care conferences (PCC)
  10. Document accurate and ongoing assessment of patient status via a variety of mediums of communication (verbal, written, email, computer documents and databases). Document patient care reflecting nursing interventions, patient response to care, patient needs, problems, capabilities, limitations, and progress toward goals. Documentation includes evidence of appropriate patient/significant other teaching, and the understanding of these instructions is noted in the medical record. Maintain up-to-date charts and records on patient care and regular communication with the patient’s physician regarding changes in the patient’s plan of care.
  11. Investigate and follow through on unusual orders or requests for service or information.
  12. Perform blood draws if required.
  13. Participate in the agency’s on-call rotation as prescribed by the needs of the agency to provide nursing service to clients when required outside office hours.
  14. Be available, when possible, to meet a patient/family’s need for continuous care in time of crisis.
  15. Coordinate community resources and other agency disciplines participating in patient care.
  16. Minimize non-productive time and fill slow periods with activities that will enable you to prepare to meet the future needs of Anchor Hospice.
  17. Supervise and maintain ongoing effective communication with other hospice personnel involved with patient care. This may involve formal and informal team meetings in addition to PCC.
  18. Knowledge of and availability to perform patient intakes and information visits as needed including explanation of the hospice benefit/Medicare, complete physical assessment, completion of all pertinent paperwork, and communication of new patient status to the HOV team.
  19. Knowledge and availability to handle patient information calls and overflow of intake/Triage calls.
  20. Provide bereavement resources to the family as appropriate.
  21. Participate in hospice and community health programs as requested to promote the growth and understanding of the hospice concept.
  22. Participation in Anchor Hospice functions including attendance a minimum of 3 Anchor Hospice sponsored in-services per year.
  23. Establish HHA plan of care as well as indirectly and directly supervising the plan of care per regulations.
  24. Perform as a member of the Anchor Hospice team as a whole and participate in the Total Quality Management philosophy.
  25. Performs other duties as assigned consistent with skills and training and the mission and goals of the Anchor Hospice.
Position Qualifications
  1. Graduate of an accredited school of nursing: Bachelor’s degree in nursing required, Masters Degree preferred.
  2. Registered nurse with current licensure to practice professional nursing in the state of Texas
  3. Minimum of eight (8) years of clinical experience including five (5) years in a managerial role in a healthcare environment; preferably a hospice environment.
  4. Demonstrated skills in administrative performance, including expertise in written/oral communication, supervision of staff, documentation requirements, service coordination and case management.
  5. Comprehensive knowledge of nursing practice, applicable rules and regulations and industry standards pertaining to hospice care.
  6. Computer proficiency and a working knowledge of Microsoft programs required.
  7. Current CPR certification.
  8. Valid Texas Drivers License and daily access to a reliable and insured vehicle.
  9. Belief in the hospice concept.
Working Conditions (Travel, Hours, And Environment)
  1. Able to work part time or PRN, with some weekend work
  2. Holiday coverage per holiday schedule.
  3. 90%  weekly travel without restriction;  0% overnight travel
  4. This position is a salaried.
Physical/Sensory Requirements (With Or Without The Aid Of Mechanical Devices)
  1. Standing, sitting, walking, lifting up to 50 lbs on a frequent basis. Has well-developed motor coordination and manual dexterity to perform basic skills. Must have good vision, hearing, speech and language abilities to perform and communicate Hospice case manager RN activities.
  2. The Hospice case manager RN position requires the following in lifting (any lifting over 35 pounds requires the use of an assistive device/and or physical assistance):
Never Occasionally Frequently Continuously
Up to 10 lbs   X  
11-24 lbs   X  
25-34 lbs   X  
35-50 lbs   X  
51-74 lbs   X  
75-100 lbs  x    
Above 100 lbs    x    

OSHA Category Classification Category I: Tasks that involve exposure to blood, body fluids or tissues.  This includes all procedures or job related tasks that involve inherent potential for mucous membrane or skin contact with blood, body fluids or tissues, or potential spills or splashes of them.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job related tasks other than those stated in this description.

I have read and understand the above job description.  By signing below, I certify that I meet the minimum requirements and physical demands of the job and will comply with all Anchor Hospice policies and procedures.