Location: Charlton,MA, USA
POSITION SUMMARY:
The RN Case Manager Hospice is responsible for the provision of patient care clinical assessments assigned to them, and assist with the development of the plan of care in accordance with the attending physician and the Interdisciplinary Team. Coordinates patient care services by providing updates to HMO for skilled residents, and is actively involved in the discharge process in conjunction with the unit manager, and social worker for PAU unit.
PRINCIPLE DUTIES/ESSENTIAL FUNCTIONS:
The following duties are normal for this position. This list is not to be construed as exclusive or all inclusive. Other duties may be required and assigned.
Responsible for the assessment, planning, implementation and evaluation of care of patients.
Obtains data on the physical, psychosocial, spiritual and other factors that may influence the patient/family health status and incorporates the data into the plan of care.
Communicates with physicians, members of the Interdisciplinary team and other agencies to coordinate optimal care and resources for the patient/family.
Maintains regular communications with the PAU manager and Social Worker to review care and participate in the discharge process.
Attends the Interdisciplinary Risk meeting and Baseline Care plan meeting and other patient conferences as deemed necessary.
Functions as a liaison between all HMO disciplines approving skilled level care for PAU unit residents.
Maintains the patient medical record and other documentation in accordance with agency standards. Records problems, plans, actions and goals accurately and concisely in the patient record so that changes are reflected as they occur.
Receives phone calls from patients, their families, physicians, health and other service providers, medical suppliers, payers and members for purposes of facilitating timely and appropriate provision of patient services and maintenance of communication/exchange of information.
Coordinates patient care by all service disciplines in PAU settings.
Participates in quality management and safety activities.
Performs duties according to the standards of nursing practice.
Adheres to policies and procedures set forth by the agency.
Maintains required licensure, certifications and vaccinations as required.
Performs other duties as required.
QUALIFICATIONS: