RN Case Manager – Hospice – Senior Services – Fairview Health Services – Minneapolis, MN

Maintains an individualized plan of care, related to the patients needs, in collaboration with the physician, patient and significant others. Determines appropriate utilization of resources based on clinical assessment and hospice or home care standards of care.

Continually reassess the patients health status, environment, and support system with ongoing comprehensive assessment. Plans maximize independence of patient/caregiver. Evaluates the patients progress and response to care/services delivered and adjusts the plan accordingly.

Continually reassess resource utilization as patient progresses. Reviews, prioritizes and implements POC based on payer limitations.

Coordinates an interdisciplinary team of clinicians to ensure patient needs are met and the utilization of evidence-based practice for best possible outcomes.

Accountable for managing the clinical care to achieve desired patient outcomes: , Hospice – self-directed life closure.

Communicates consistently and effectively with patient, caregiver, significant others, physicians and all team members to assure appropriate implementation and completion of the patient plan of care.

Advances the POC with the multidisciplinary team. Consults with the other team members as needed to make modifications in the plan. Home Care -decreases utilization of services as patient moves towards goal achievement.

Supervises paraprofessional staff in patient care.

Attends and participates in patient care rounds to elicit recommendations from team members as needed to make modifications in the plan of care.

Hospice:
Symptom management for the terminally ill patient, in collaboration with the patients MD, Fairview pharmacist, Hospice Medical Director, and interdisciplinary team members.

Participates in patient and family conferences as indicated in the care plan. Facilitates discussions of care issues and ethical decision making as appropriate.

Communicates/coordinates scheduling with Clinical Support staff.Assumes on-call responsibilities as necessary and assigned.

Maintains complete, accurate, legible and timely clinical records/ documentation on all patients according to agency policy.

Completes majority of documentation at the point of care.

Meets all compliance measures (ex: MD orders, insurance authorization, patient rights). Timely submission of all documentation.

Regular communication with manager regarding concerns and problem solving.

Fiscal Accountability: 1) is a good steward of resources: discipline utilization, visits and supplies 2) maintains productivity standards.

Manages the patient care episode within payer limits (visits and supplies).

Provides safe, effective skilled and advanced intervention, within scope of practice according to patient need.

Provides counseling and teaching of patient, family and caregiver regarding care needs and health promotion/prevention.

Evaluates and documents response to care/services delivered.

Stays current (expert) in home care and / or hospice regulation and all applicable licensing.

Performs other duties as assigned.

Qualifications

Required

Must have one or more of the following:
One-year recent RN experience or One-year LPN experience in Fairview Home Care and Hospice or One-year TCU or SNF experience

Computer skills (able to document effectively in EMR)

Licensed as a RN and eligible to practice in Minnesota

Current CPR (BLS for Health Care Providers) certification

Preferred

Bachelors degree in nursing

Previous RN experience in high-tech home care or hospice, med/sug, oncology, or critical care

Public Health Nurse (PHN) certification

Additional Requirements:
Must have reliable transportation

Current Minnesota drivers license (or license that matches your permanent residence)

Must carry current and adequate automobile insurance

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Internal Number: 2020-61957