Case Manager

Description

PURPOSE OF POSITION

To serve as a member of the team to provide appropriate and adequate professional nursing care as prescribed by the physician in compliance with applicable RN licensure and agency policies and procedures to those patients who desire to receive hospice care.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Listed below is an outline of the essential duties and responsibilities that will be required. Administrative authority, responsibility, and accountability necessary to perform the assigned duties under the supervision of the Team Leader are delegated to the Case Manager.

Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the position.

DUTIES AND RESPONSIBILITIES

1. Skilled Nursing Services
2. Performs physical, psycho-social and spiritual assessment at start of care and establishes plan of treatment in cooperation with remainder of IDG members. Submits paperwork within 24 hours of assessment.
3. Performs intermittent skilled nursing evaluation on assigned patients. Documentation within 24 hours of evaluation.
4. Assess and documents current pain level and outcome with every visit. Complete pain assessment minimum of once per week on all patients assigned.
5. Instructs patient’s family and caregivers as appropriate to overcome identified knowledge deficits, documents in notes and home charts.
6. Reports changes in patient’s condition to Team Leader weekly and physician as appropriate.
7. Obtains physician orders and implements interventions and changes in treatment as appropriate. Documents phone contact that same day.
8. Monitors medication levels at each visit, insuring the patient always has sufficient quantity, but adjusts levels to coordinate with patients declining status.
9. Makes appropriate referrals to other disciplines, recognizing need for additional assistance.
10. Initiates prescribed treatment and evaluate medication effectiveness as designated in the POT within 24 hours of implementation.
11. Makes visits at the time of death of patient to pronounce death as authorized by the attending physician.
12. Coordinates minimum of 3 visits per week with SS for all hospitalized patients.
13. Visits all patients within 24 hours of hospital discharge.
14. Makes follow up visits within 24 hours of SOC, completing the plan of care and the CNA plan of care.

2. Administration

1. Provides appropriate documentation at start of care visit within 24 hours of admission.
2. Revises POT minimum of every 2 weeks, more often PRN with changes in level of care, medication, treatment, and informs all members of IDG of all changes. Insures care plan matches visit notes.
3. Provides appropriate documentation of intermittent skilled nursing visits and all patient related telephone calls within 24 hours of contact.
4. Coordinates placement of appropriate paper work on hospital chart for hospitalized patients within 24 hours of hospitalizations.
5. Provides instruction, leadership, and direction to LVNs as needed.
6. Provides instruction, leadership, and direction to CNAs as well as supervisory performance evaluations every 14 days.
7. Clears all chart deficiencies every week with HIMS.
8. Transcribes orders from physicians and updates medications and records daily. Informing all necessary team members. Documenting all communication.
9. Updates home medication record with every visit.
10. Prepares bi-weekly patient care reports. Has a report available 2 days prior to care conference. Documents minimum of 1 phone contact with family every week for all patients in nursing facilities or foster homes.
11. Complies with agency policies and procedures, mission and values statement.
12. Attends PCC at nursing facility PRN, informs IDG of outcome.
13. Provides accurate care status report every Monday to Team Leader.
14. Revises CNA care plan.
15. Provides leadership, supervision to personnel when assigned.
16. Provides shift report daily to Team Leader at assigned time and format.
17. Executes duties as assigned by the Team Leader.
18. Covers after hours and weekend call as needed.
19. Responds to pages in a timely manner.
20. Synchronizes laptop daily.
21. Performs recertifications in a timely matter.

3. General

1. Shall know and conform to the Texas Nursing Practice Act as delineated in Title 3, Subtitle E, Chapter 301 of the Texas Occupations Code, the Board of Nurse Examiner’s standards, rules and regulations as delineated in Title 22, Part 11 of the Texas Administrative Code, as well as all federal, state, or local laws, rules or regulations affecting the nurse’s current area of nursing practice.
2. Maintains Licensure as required by Title 3, Subtitle E, Chapter 301 of the Texas Occupations Code and Title 22, Part 11 of the Texas Administrative Code.
3. Notifies Hospice immediately of any pending action against the license or pending suspension or any suspension or action taken against the license.
4. Has knowledge of and follows Hospice policies and procedures.
5. Maintains a professional appearance.
6. Displays a consistent positive attitude.
7. Demonstrates Values of Hospice: PROFESSIONALISM * RESPECT * NURTURANCE * COMMUNICATION * CONTINUOUS IMPROVEMENT
8. Adheres to Hospice of El Paso Mission and Value Statement.
9. Performs other duties as assigned.

COMMUNICATION

1. Establishes and maintains effective communication and a cooperative manner with patient, members, physicians, hospital, nursing home and foster care personnel.
2. Establishes and maintains effective communication and a cooperative manner with Hospice administration, volunteer and patient care departments, all members of the team, and all employees of Hospice of El Paso.
3. Listens and responds to the patient/ family needs in a sensitive and timely manner keeping all parties (IDG) appraised of developments.
4. Complies with HIPAA standard by abiding with the minimum necessary Protected Health Information to perform job function. Access Level 2 = Select, insert, update.

PROFESSIONAL DEVELOPMENT

1. Attends and participates in weekly team and IDG meetings and bereavement conferences.
2. Attends and participates in in-services, education classes and on-the-job-training programs as required to maintain competency levels.
3. Participates in initial competencies upon hire and annually thereafter.
4. Attends workshops and seminars as approved.
5. Participates in orientation of employees, volunteers, and students as assigned.
6. Involved in community/civic health matters/projects.
7. Attends ethics and compliance training and maintains compliance with the CCP.

WORKING CONDITIONS

1. Works in patient’s home setting, as well as throughout the nursing service areas.
2. Subject to frequent interruptions.
3. Involved with physicians, patients, family members, personnel, visitors, government agencies/personnel, etc., under all conditions/circumstances.
4. Subject to hostile and emotionally upset patients, family member, etc.
5. Willingness to work beyond normal working hours, and in other positions temporarily, when necessary.
6. Subject to falls, burns from equipment, infectious disease, odors, etc., throughout the work day.
7. Exposure Level – Category I. Direct contact with blood, other bodily fluids and potentially infectious materials to which standard precautions apply. Personal protective equipment is made available and must be worn.

Requirements

QUALIFICATIONS

1. Education and Experience
2. Current licensure as a Registered Nurse in the State of Texas.
3. Two years clinical experience. Background in oncology, discharge planning, care of terminal patients or community nursing health preferred.
4. Other
5. Must be able to read, write, and speak English at a level which will permit the employee to accurately understand and communicate information as necessary to safely and efficiently perform job duties.
6. Ability to work independently and with flexibility.
7. Personal vehicle available for transportation during work hours and personal phone.
8. Valid driver’s license and auto insurance as required by the state of Texas.

PHYSICAL REQUIREMENTS

1. Sits, bends, lifts and walks intermittently during working hours. Is able to sit for prolonged periods.
2. Is able to reposition up to 50 pounds of weight.
3. Possesses sight/hearing senses, or uses prosthetics that enable these senses to function adequately, so that the requirements of this position can be fully met.