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Hospice RN - Case Manager

Tybee & Company
West Bloomfield Township, MI
June 30, 2020


Provide skilled nursing assessment, planning, and coordination of services in order to maximize the comfort and health of patients and families, under the general direction of the Medical Director and/or the attending physician. Educate contracting facilities and community members and meet with multidisciplinary team and groups to market hospice services.

• Accurately complete required documentation within 24 hours of patient visit

• Assume responsibility for a patient/family caseload that includes the assessing, planning and implementation, and evaluation phases of the nursing process

• Initiate communication with attending physicians, multidisciplinary hospice team members, and agencies as needed to coordinate optimal care and use of resources for the patient/family

• Communicate with physicians, agencies, and team to coordinate patient/family care

• Obtain data on physical, psychological, social, and spiritual factors that may influence patient/family health status and communicate that data in team meetings to formulate an Interdisciplinary Plan of Care

• Maintain up-to-date patient records so that problems, plans, actions, and goals are accurately and clearly stated and changes are reflected as they occur

• Coordinate physical care of the patient and instruct primary caregivers, volunteers, and Home Health Aides in providing direct care as appropriate

• Review and update Hospice Certified Nursing Assistant care plan per agency guidelines and standards

• Attend interdisciplinary team meetings to facilitate discussion of patient/family status in order to evaluate and revise the interdisciplinary team plan of care

• Provide appropriate support at time of death and period of bereavement as needed

• Complete all mandatory education requirements

• Represent the company in professional and community activities as requested

• Attend and participate in all required agency meetings

• Understand Medicare-disease specific criteria, hospice level of care, and hospice benefit

Job Description

• Ensure the clients have prescribed medications and/or treatment supplies, updating file as changes occur

• Profile/reconcile medications in conjunction with pharmacy vendors and physician

• Follow up as needed and appropriately with doctor’s office, hospice multidisciplinary team, and management staff pertaining to any concerns regarding patient care

• Communicate with physicians, agencies, and team to coordinate patient/family care

• Participate in quality initiatives with problem-solving via action items

• Comply with Company’s Core Values and Core Competencies

• Perform other duties as assigned by supervisor

Job Requirements and Responsibilities:

• Associate degree from an accredited School of Nursing

• 1+ years of experience working as a RN, including Hospice experience

• Hold license as a Registered Nurse issued by the state in which you work

• Experience with HomeBaseHomeCare, Residential's EMR, is preferred

• CPR and BLS certified

• Valid driver's license and access to automobile

• Able to meet the physical demands of providing nursing care, ambulating patients, transferring patients, assisting with exercises, etc.

• Able to transfer patients as needed according to proper techniques of body mechanics to promote patient and staff safety