Job Summary
The Nurse Case Manager (NCM) is a member of the core interdisciplinary team responsible for the care and case management of patient/families admitted to hospice service. The NCM in collaboration with pt/family, physician and interdisciplinary team, develops and coordinates an individualized Plan of Care (POC) that reflects pt/family goals related to Safe & Comfortable Dying, Self-Determined Life Closure and Effective Bereavement. The NCM demonstrates: sensitivity and compassion for the issues involved with serving patients and families facing a terminal illness, death and bereavement; clinical competence in pain and symptom management; and fiscal responsibility in the planning and delivery of services. The Nurse Case Manager provides direct supervision for Hospice Aides and LVNs, when utilized. Occasional weekend availability required.
Essential Responsibilities
Patient/family care
Recognizes the patient and family as the "unit of care" and active members in the development of the POCRespects patient right to self-determination and acts as advocate within the context of the values and ethical standards of HSCC. Meets pt/family where they areUtilizes nursing process in providing primary care to pt/familiesDocuments all care and care planning per agency policyProvides nursing interventions for pt/family as ordered by the physician and in accordance with the POC, safe nursing practice and the policies and procedures of HSCCAssesses and monitors management of pain and symptoms in collaboration with patient/family, IDG and physician to achieve maximum comfortExercises good clinical judgmentAdministers medications and treatments as ordered prnDemonstrates the ability to articulate the parameters of hospice care and servicesDemonstrates the ability to work with pt/families under stress & in crisisDevelops, manages, reviews & revises HA POC & supervises HA performance per HSCC policies & proceduresReviews and considers patient data gathered by LVN/HHA when developing and revising the plan of care.Instructs and supports pt/family unit re: symptom mgmt, patient care, disease process & death/dyingParticipates in providing after-hours coverage to pt/family as neededCase Management
Visit frequencies are appropriate to patient statusPlans & provides care within the structure of the Conditions of Participation & the Hospice Medicare/Medi-Cal BenefitCollaborates with IDG & Attending Physician to develop, manage, review and revise a written POC that includes identified goals, interventions and outcomes that address pt/family physical, psychosocial and spiritual goals related to Safe & Comfortable Dying, Self-Determined Life Closure and Effective GrievingOpens, closes & revises POC per HSCC guidelinesDocuments all contacts/instructions/ interventions per HSCC policies & proceduresObtains medications, medical supplies and equipment per pt need/physician orderDemonstrates understanding of pharmacy-related policies & proceduresAssess patient's continued appropriateness for hospice care per HSCC Recertification protocolsCompletes Recertification documentation in a timely and accurate mannerExercises professional management and coordinates care between and among involved parties in home, SNF and RCFE settingProvides concise and timely on call reportsSubmits completed paperwork & time sheets within the timeframes per HSCC policies & proceduresQuality Improvement
Meets all standards and requirements as indicated by licensing and accrediting agenciesSubmits verification of current employment related documents per HSCC policies, procedures and licensing agenciesCompletes and submits all documentation in accordance with policies and proceduresParticipates in activities that affirm, enhance and develop the highest quality standards for HSCCParticipates in developing standards for quality patient care within HSCCParticipates in Quality Assessment & Improvement activities as requestedVerbal communication is concise, organized and timely per HSCC guidelinesCompletes and submits all documentation in accordance with policies and proceduresSubmits verification of current RN License, TB status, passes OIG/GSA checks, proof of auto insurance/good driving record in a timely manner per HSCC policies, procedures and licensing agenciesIDG Participation
Functions as a member of the HSCC IDG maintaining open & organized communication with hospice staff, volunteers and supervisorFunctions as Nurse Case Manager for hospice pts/families in the coordination/provision of nursing servicesParticipates in IDG meeting per protocol to promote problem solving, care planning and learningMaintains open, organized and timely communication with hospice staff / volunteersWorks collaboratively with IDG to develop common goals to meet the needs of the patient and familySpecial Projects
Participates in special projects as requestedPerforms other related job duties as assigned by SupervisorCompliance
Ensures all HIPAA Privacy and Security Regulations, Medicare Conditions of Participation, and all other regulatory/compliance requirements are understood and followedSubmits verification of current RN licenseSubmits proof of auto insurance annually; keeps drivers license current and maintains a good driving recordEnsures TB checks are completed in a timely manner; at least annuallyRequirements
Certifications, Licenses, Registrations
Require current California RN licenseValid state driver's license and liability auto insurancePass OIG/GSA review and all required background checksEducation/Experience
Degree in Nursing from an accredited college2-5 years RN experience in hospice, oncology, medsurg, ICU, ER, skilled nursing facilities or homecare 1 year minimum of Acute care experience preferredPrevious experience working with electronic medical record charting is desirableHospice and/or home health experience preferredEnd-of-life and pain management experience preferredPrefer technical experience with ports, IV's, TPN, Oncology, Medsurg, ICU or Homecare and Electronic Medical Record keepingRequires ability to effectively manage self and stress related to end-of-life/death and dying experiences. Experience in handling emotionally charged situations in calm, respectful manner. And has strong coping skillsSkills Desired
Previous experience working with end of life is desirableBilingual in English/Spanish requiredPhysical Demands
Sufficient dexterity to utilize electronic record keeping systems, computers/keyboards and or laptops and other related equipmentAbility to travel to patient locations; includes ability to drive, negotiate stairs and walkways including uneven surfaces at private homes or facilitiesVision ability to read manual and electronic documentation, medications, charts, office related equipment, and instructionsHearing ability within normal range to elicit and detect pertinent information while communicating with patients and health teamSpeech to verbally communicate to assess and impart information concerning patient status; to complete patient/family teaching and to interact with health care teamWork Environment/Environmental Condition
Performs services in private homes and care facilities and will experience a variety of settings and situations Office work is performed in typical office settingSchedule options (all options are benefits eligible):
8 hour shifts, Monday - Friday, or Tuesday - Friday.
10 or 12 hour shifts Fri/Sat/Sun.
Highly desired bilingual (e/s)
Job Summary
The Nurse Case Manager (NCM) is a member of the core interdisciplinary team responsible for the care and case management of patient/families admitted to Kid WISE service. The NCM in collaboration with pt/family, physician and interdisciplinary team, develops and coordinates an individualized Plan of Care (POC) that reflects pt/family goals related to safe and comfortable pediatric life limiting Illnesses, enhancing quality of life for child and family, promoting self-determined life closure and effective bereavement. The NCM demonstrates: sensitivity and compassion for the issues involved with serving patients and families facing a terminal illness, death and bereavement; clinical competence in pain and symptom management; and fiscal responsibility in the planning and delivery of services. The Nurse Case Manager provides direct supervision for Hospice Aides and LVNs, when utilized. The Nurse Case Manager will be cross-trained in adult hospice/palliative care, and provide adult hospice nursing care when reasonable and necessary.
Essential Responsibilities
Patient/family care
Recognizes the patient and family as the "unit of care" and active members in the development of the POCRespects patient right to self-determination and acts as advocate within the context of the values and ethical standards of HSCC. Meets pt/family where they areUtilizes nursing process in providing primary care to pt/familiesDocuments all care and care planning per agency policyProvides nursing interventions for pt/family as ordered by the physician and in accordance with the POC, safe nursing practice and the policies and procedures of HSCCAssesses and monitors management of pain and symptoms in collaboration with patient/family, IDG and physician to achieve maximum comfortExercises good clinical judgmentAdministers medications and treatments as ordered prnDemonstrates the ability to articulate the parameters of Kid WISE services. Demonstrates the ability to work with pt/families under stress & in crisisDevelops, manages, reviews & revises HA POC & supervises HA performance per HSCC policies & proceduresReviews and considers patient data gathered by LVN/HHA when developing and revising the plan of care.Instructs and supports pt/family unit re: symptom management, patient care, disease process & death/dyingParticipates in providing after-hours coverage to pt/family as neededParticipates in coverage of adult hospice care when reasonable and necessary.Case Management
Visit frequencies are appropriate to patient statusPlans & provides care within the structure of the Conditions of Participation & the Hospice Medicare/Medi-Cal / Concurrent Care BenefitCollaborates with IDT & Attending Physician to develop, manage, review and revise a written POC that includes identified goals, interventions and outcomes that address pt/family physical, psychosocial and spiritual goals related to Safe & Comfortable Dying, Self-Determined Life Closure and Effective GrievingOpens, closes & revises POC per HSCC guidelinesDocuments all contacts/instructions/ interventions per HSCC policies & proceduresObtains medications, medical supplies and equipment per pt need/physician orderDemonstrates understanding of pharmacy-related policies & proceduresAssess patient's continued appropriateness for Kid WISE services per HSCC Recertification protocolsCompletes Recertification documentation in a timely and accurate mannerExercises professional management and coordinates care between and among involved parties in home, community providers and pediatric tertiary specialist.Information Visits and Admissions
Conducts information visits and discusses Kid WISE services, explain benefits and eligibility, and answer questionsAdmit patients on to Kid WISE services, coordinate services, order DME and medicationsDevelops and implements individualized POC based on patient and families goalsReview consents with patient/family and obtain signaturesQuality Improvement
Meets all standards and requirements as indicated by licensing and accrediting agenciesSubmits verification of current employment related documents per HSCC policies, procedures and licensing agenciesCompletes and submits all documentation in accordance with policies and proceduresParticipates in activities that affirm, enhance and develop the highest quality standards for HSCCParticipates in developing standards for quality patient care within HSCCParticipates in Quality Assessment & Improvement activities as requestedVerbal communication is concise, organized and timely per HSCC guidelinesCompletes and submits all documentation in accordance with policies and proceduresSubmits completed paperwork & time sheets within the timeframes per HSCC policies & proceduresSubmits verification of current RN License, TB status, passes OIG/GSA checks, proof of auto insurance/good driving record in a timely manner per HSCC policies, procedures and licensing agenciesSpecial Projects
Participates in special projects as requestedPerforms other related job duties as assigned by SupervisorCompliance
Ensures all HIPAA Privacy and Security Regulations, Medicare Conditions of Participation, and all other regulatory/compliance requirements are understood and followedSubmits verification of current RN licenseSubmits proof of auto insurance annually; keeps driver's license current and maintains a good driving recordEnsures TB checks are completed in a timely manner; at least annuallyRequirements
Certifications, Licenses, Registrations
Require current California RN licenseValid state driver's license and liability auto insurancePass OIG/GSA review and all required background checksEducation/Experience
Degree in Nursing from an accredited college2 years of pediatric nursing experience or 2 years of hospice or home health nursing experiencePrevious experience working with electronic medical record charting is desirableEnd-of-life, pain management, complex care experience preferredPrefer technical experience with Ports, IV's, TPN, Trachs, Oncology, Medsurg, NICU/PICU or Homecare Requires ability to effectively manage self and stress related to pediatric life limiting illnesses /end-of-life /death and dying experiences. Experience in handling emotionally charged situations in calm, respectful manner. And has strong coping skillsSkills Desired
Previous experience working with end of life is desirableBilingual in English/Spanish highly desiredPhysical Demands
Sufficient dexterity to utilize electronic record keeping systems, computers/keyboards and or laptops and other related equipmentAbility to travel to patient locations; includes ability to drive, negotiate stairs and walkways including uneven surfaces at private homes or facilitiesVision ability to read manual and electronic documentation, medications, charts, office related equipment, and instructionsHearing ability within normal range to elicit and detect pertinent information while communicating with patients and health teamSpeech to verbally communicate to assess and impart information concerning patient status; to complete patient/family teaching and to interact with health care teamWork Environment/Environmental Condition
Performs services in private homes and will experience a variety of settings and situationsOffice work is performed in a typical office setting