Hospice of the East Bay: RN Case Manager Position

Status: Full-time, Benefited

Schedule: M-F Days

 About Us

Hospice of the East Bay (HEB) is a community based program of home care for terminally ill patients. Care is given to patients and families by an interdisciplinary group. Bereavement care is provided to the family for one year after the death. Hospice services are given regardless of ability to pay, making the agency dependent on donations and insurance billing to meet operating expenses.

Employee Benefits

Hospice East Bay is committed to providing a comprehensive benefits and compensation package for our employees. Our health benefits include 100% employer-paid premiums for our high deductible medical plan offered with a Health Savings Plan partially employer funded for eligible employees.  Employer paid dental and vision premiums,  Additional benefits include generous paid time off program, educational assistance, and employer-matched contributions to our retirement plan (up to $2,000 annually), Life/AD&D coverage, a comprehensive Employee Assistance Program, and convenient discounts on many services, including gym memberships, dry cleaning, produce delivery, mobile phone service, and automotive care.

Position Summary

Reporting to the Team Manager, the Hospice Registered Nurse Case Manager is responsible for identifying the patient’s and family’s physical, psycho social, environmental, safety and developmental needs and individualizing the patient’s plan of care based on the needs identified. The Hospice RN Case Manager coordinates patient/family care and ensures continuous assessment of each patient and family’s needs and implementation of the interdisciplinary plan of care under the direction of the attending physician and Medical Director/Hospice physician in conjunction with the interdisciplinary team.

Hospice nursing services are based on the initial and ongoing comprehensive assessment of the patient's needs and are provided in accordance with the interdisciplinary team's care plan. Each Case Manager triage's and coordinates the care of up to 15 patients with the assistance from Revisit Nurses and in collaboration with the Team Manager.

Essential Functions

• Identify and address signs of actively dying
• Communicating and collaborating with patient care, MSW and SCC

Hospice nursing services include:

• Assessing all aspects of the patient’s pain and developing an individualized pain management plan.
• Anticipating, preventing and treating undesirable symptoms or secondary symptoms
• Identifying and addressing comfort care needs.
• Supporting, instructing and educating the patient, family and caregiver using teach back.
• Documenting problems, nursing assessments, appropriate goals, care provided, care interventions and patient and family outcomes achieved from intervention and care provided.
• Maintaining the dignity, confidentiality and privacy of the dying patient.
• Supporting the patient’s unique spiritual and cultural beliefs.
• Providing holistic, family-centered care across treatment settings to improve the quality of life.
• Consulting and collaborating with the interdisciplinary team and others involved in the patient’s care.
• Coordinating and managing patient care with awareness of insurance benefits, necessary authorizations and cost containment.
• Coordinating patient care plan with After Hours and Crisis Care Staff.
• Attend, document and present appropriate patient-related information at the Interdisciplinary Team Meetings utilizing the IDT templates.
• Updating the comprehensive assessment and patient’s progress towards desired outcomes at least every 15 days.
• Supporting the patient’s unique spiritual and cultural beliefs.
• Completing patient-related documentation within 2 hours of the shift worked.
• Adhering to and complies with state and federal regulations, as well as accreditation standards.
• Providing patient and primary caregiver education/training, as appropriate, for care and services identified in the plan of care.
• Adhering to evidence based standards of practice that are endorsed by the agency.
• Identify and address signs of transitioning
• Coordinate care for transfers to GIP level of care
• Coordinate care for transfers to respite level of care
• Coordinate care with Ahf, RCFE, & SNF
• Educate and document education of caregivers (home and facility) utilizing appropriate educational tools.

Other Case Management responsibilities:

• Communicating with Team Manager as appropriate regarding patient acuity, scheduling, workload, and difficult situations.
• Completing necessary records, reports and documentation in a timely manner according to agency requirements.
• Following the agency’s process for effective hand off communication.
• Participating in educating new staff members as assigned by the Team Manager.
• Supervising performance of Home Health Aide.
• Supervising performance of LVN.
• Attending appropriate in-services held for Hospice of the East Bay staff.
• Participating, as requested, in QAPI activities.
• Initiating and ongoing monitoring of medication reconciliation processes according to Medicare and accreditation standards.
• Respond to email and voice mail communication in a timely manner.