Nurse Case Manager - Hospice Registered Nurse
Overview
We are a leading physician group serving South Carolina and Georgia, dedicated to delivering quality healthcare directly to patients in care facilities, homes, clinics, and virtual visits. Our services include comprehensive primary care, specialty services, and pharmacy support, tailored to meet diverse patient needs. We are seeking a Registered Nurse to service our patients throughout the Charleston area. The role of the Nurse Case Manager is a critical part of the patient’s care team. The nurse will visit patients and coordinate with the appropriate provider. Travel to patients’ homes and facilities (e.g., long-term care facilities) is required to evaluate patients and initiate telemedicine visits. Provide quality healthcare in adherence to all applicable laws, regulations, and policies within the scope of practice.
Service area and schedule
The Following Service Area(s) Are Currently Available: Summerville/Charleston area. This is a full-time, salary-based position with 12-hour or 8-hour shifts. You must have reliable transportation as travel is required daily.
What we’re looking for
Your Health is seeking a Registered Nurse to join our growing primary care family. A successful Nurse Case Manager will perform essential duties and responsibilities. Reasonable accommodations may be made, in accordance with applicable law, to enable individuals with disabilities to perform the essential functions.
Responsibilities
Facilitate receiving all medical records from the patient’s primary provider and specialists.
Review medical records.
Complete consents with patients.
Enroll patients in Care Management, if they meet eligibility criteria.
Initiate a Care Management Plan of Care, if the patient is eligible.
Capture all diagnoses at the highest specificity by creating gaps and ensure they are accepted.
Complete AWV’s to be reviewed by the provider.
Complete cognitive impairment screenings.
Complete Social Determinants of Health (SDoH) assessments and/or screenings.
Complete ACP’s to be reviewed with the patient by the provider.
Evaluate for home health, hospice, palliative, or consults with Your Health Specialty Division, etc.
Evaluate for RPM devices, resources, or tools that may improve the patient’s quality of life.
Communicate and coordinate care.
Reconcile prescribed and OTC medications, vitamins, supplements, herbal remedies, and other treatments.
Provide post-discharge education.
Evaluate for adaptive equipment and DME.
Evaluate for a safe environment.
Evaluate acute condition(s) or follow-up from previous visit.
Document and log Care Management activities accurately. Work with the care team to keep care plans up to date.
Coordinate with the patient’s health care team, providers, therapists, home health or hospice representatives, and other individuals in the patient’s care plan.
Facilitate visits with the appropriate provider or entity.
Facilitate a telehealth visit with a provider for coordination of care, when necessary.
Coordinate with the patient’s hospice interdisciplinary team and other individuals in the patient’s care plan.
Participate in IDG meetings, when necessary.
Qualifications
Must be a Registered Nurse. License must be in good standing with the appropriate board/issuer.
A minimum of three (3) years clinical experience preferred.
Experience in community settings preferred.
Proven ability to effectively communicate and collaborate with interdisciplinary care teams, patients, and caregivers.
Strong written and verbal skills.
Basic computer knowledge.
Ability to manage and demonstrate effective leadership skills.
Good interpersonal and communication skills under all conditions.
Ability to foster a cooperative work environment.
Team-oriented with ability to manage multiple responsibilities and exercise sound judgment.
Must be able to work flexible hours and travel between offices, facilities, etc. Must be a licensed driver with an automobile insured as required and in good working order.
Note : This description reflects the core responsibilities and qualifications for the Nurse Case Manager - Hospice Registered Nurse role. It does not include every task that may be assigned.