Job Summary

The palliative case manager, will have a special opportunity to provide, coordinate and direct the provision of care for those patients with complex chronic conditions that are transitioning to end-of-life stage across different care settings. You will closely collaborate with the attending physician, patients and their families, and other members of the patient care team to provide and maintain continuity of patient care to achieve excellent symptom, pain management and high quality of care, up to the end-of-life care for the patient.

Essential Duties and Responsibilities

The duties listed below are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment. Description provides some of the case management duties, not limited to physician’s orders and application of the nursing process.

  • Implements interventions to support the patient with chronic conditions to decrease the recurring hospitalizations. Monitors the effectiveness of interventions
  • Coordinates the total plan of care and maintains continuity of patient care by collaborating with other health professionals assigned to same patient. Attends weekly interdisciplinary (IDT) meetings. Initiates patient care conferences for complex and/or multi-disciplinary patients whenever needed
  • Develops, prepares, and maintains individualized patient care visit records that reflect the patient’s plan of care with accuracy, timeliness
  • Evaluates, and regularly re-evaluates, appropriate level of care. Assesses the patient’s continual care needs. Addresses all problems in the plan of care or documents rationale
  • Monitors and supervises Supportive Care staff; ensuring that care aligns with the plan of care and that services and documentation meet guidelines
  • Supervises and teaches the home health aide. Assesses the patient’s needs for unskilled care at least every two weeks and revises the plan of care as appropriate. Communicates the plan of care changes to the aide and scheduler as often as necessary
  • Makes referrals to other disciplines as indicated by the patient’s needs or documents rationale for not doing so. Includes the patient and the family in the planning process
  • Observes signs and symptoms and reports to physician and/or other appropriate health professional as often as needed, or upon changes in the patient’s condition
  • Teaches, supervises, and counsels the patient and family regarding home nursing procedures and other care needs as appropriate to the patient’s condition
  • Assess and reassess all physical, environmental, and emotional factors to determine if a referral to hospice services is needed
  • Works in cooperation with the family/caregiver and IDT to meet the emotional needs of the patient/family/caregiver
  • Assist patients and their families with paperwork
  • Ability to conduct an advanced care discussion with a patient and their family and properly document their wishes in the electronic medical record
  • Facilitates patient transitions between health care settings.
  • Maintains knowledge of and compliance with current Medicare/Medicaid, state/federal rules, and regulations for professional (palliative care, advanced disease management, transitional and chronic care) services
  • Ensures compliance with the Medicare conditions of participation and other state regulations govern the provision of healthcare
  • Complies with all Health Insurance Portability and Accountability Act (HIPAA) requirements in accordance with federal, state, and organizational policies
  • Participates in organizational monitoring of the quality of medical services and quality improvement initiatives
  • Assumes responsibility for personal growth. Develops, maintains, and upgrades professional knowledge and practice skills through attendance at seminars, conferences and participation in continuing education and in-service classes
  • Fulfills the obligation of requested and/or accepted assignments
  • Demonstrate knowledge in communication and counseling patient/family in dealing with life limiting and end-of-life issues
  • Able to perform duties autonomously, schedule and meet workload expectations
  • Identify and report to leadership immediately any concerns or issues, that places the team, patient, or caregiver at risk
  • Excellent observation, verbal and written communication skills, problem solving skills

Qualifications

  • Graduation from an accredited School of Nursing
  • Unrestricted Registered Nurse license (Florida)
  • CPR certification
  • Minimum of one (1) year of experience as a registered nurse, experience in a clinical, hospice or hospital, rehab, or long-term care setting
  • Experience related to advanced care planning and discussions with patients regarding end-of-life wishes
  • Proficient computer skills, including Microsoft Word, Excel, Power Point and Outlook
  • Demonstrated knowledge and skills necessary to provide care to and communicate with primarily the geriatric population, and to a lesser degree the adult and pediatric
  • Able to assess data reflecting the patient’s status and interpret the appropriate information needed to identify each client’s requirements relative to their age-specific needs
  • Valid Florida driver’s license and auto liability insurance required

 

 

Preferred Qualifications

  • Previous home health or hospice experience
  • Previous Case Management experience
  • Certified Hospice and Palliative Nurse (CHPN)
  • Proficient knowledge of palliative care and end-of-life symptom management
  • 2+ years of hospice/palliative experience
  • Bi-lingual fluency in English and Spanish