RN Care Manager Phoebe Sumter Hospice

Job Summary

The Nurse Case Manager (CM) is responsible for care coordination of patients along their continuum from point of entry through discharge. The CM will address issues related to appropriate and timely admission, discharge, and care for patients receiving inpatient and observation care and services at PPHS facilities. The Care Manager performs first level clinical reviews according to hospital approved clinical criteria and in accordance with the Care Management Program's Utilization Plan and payer specific requirements.

He/she will address utilization of resources for efficient and effective care delivery at the appropriate level of care. The Care Manager collaborates with social work, physicians, nurses and multidisciplinary team, lending professional care management expertise to ensure quality, timely and cost effective case management for an identified patient population and addresses issues or patterns in patient readmission. In this role the Care Manager is accountable for facilitating clinical patient progression through a defined plan of care to achieve optimal outcomes.

Under the direction of the Care Management Team Lead, the Director of Care Management, and through coordination with nursing, social work, physicians and other members of the interdisciplinary team, the Care Manager develops, facilitates and implements appropriate case management and discharge plans.

• Associate’s degree in nursing, from a state accredited school. Required
• Bachelor’s degree in nursing, from a state accredited school. Preferred

• 3 or more years of general medical surgical nursing experience. Required
• 1 or more years of hospice or home care experience. Preferred

• RN
  - Registered Nurse
• CCM
  - Certified Case Manager Required (Within 3 Years)
• CHPN
  - Certified Hospice And Palliative Nurse. Required (Within 3 Years)
• BCLS
  - Basic Life Support. Required

• Collects data in a systematic and ongoing process
• Issues are identified and diagnoses are developed based on assessment data.
• Prioritizes data collection based on the patient's condition and needs.
• Identifies expected outcomes and plan based on diagnoses or issues.
• Directs the coordination of care across setting and among caregivers.
• Engages in teamwork as a team player and a team builder.
• Serves in key roles at work through shared decision making.
• Defines a clear vision including goals and plans and measures progress.
• Promotes nursing through participation in professional organizations.
• Documents and submits required information and data in a timely fashion.
• Clearly and accurately documents designated processes, policies, products, service offerings, etc.
• Ensures that documentation is tailored to expected readers / users.
• Uses correct terminology.
• Conforms to required style and format.
• Develops expected outcomes that provide direction for continuity of care.
• Involves patient/family and other disciplines to determine expected outcomes.
• Modifies expected outcomes based on changes in the assessment of the patient.
• Includes the patient and others involved in the care in the evaluation process.
• Evaluates the plan in relation to patient responses and expected outcomes. Documents the results of the evaluation.
• Uses the results of quality improvement activities in nursing practice.
• Uses creativity and innovation in nursing practice to improve care delivery.
• Incorporates evidence based knowledge to initiate change in nursing practice.
• Participates in quality improvement activities.
• Accountable for individual practice and delegation to provide optimum care.
• Practices with compassion and respect.
• Primary commitment is to advocate for the patient, family and community.
• Assures patient safety through competency and growth of self and others.
• Contributes to a healthy work environment through shared decision making.
• Collaborates with other health professionals to meet healthcare need.
• Adheres to established standards of interdisciplinary nursing practice and the policies and procedures of Phoebe Sumter Hospice and Phoebe Putney Health System.
• In collaboration with the patient's attending physician, if any, and the Hospice physician, the…