RN Case Manager Homecare - Middleton

RN Case Manager

Agrace is a nonprofit, community health care organization that is nationally recognized as a leader in the hospice industry. Well known for end-of-life care, Agrace also serves people across southern Wisconsin who are aging, seriously ill, or grieving.

Agrace has a strong culture of employee engagement. In 2023, Agrace was named the Top Workplace by the Wisconsin State Journal and Energage, and one of the top 100 companies in the country among those with an employee base of 500 to 999 workers!

Job Description

• The RN Case Manager works on a collaborative interdisciplinary team including Social Workers, RNs, CNAs, Volunteer Coordinators, and Clinical Assistants.
• The RNCM is responsible for patient and family satisfaction through the provision of nursing care and case management by conducting assessments, creating and updating the plan of care, providing interventions, communicating, and documenting.
• Assess patients and family's physical, pain, psychosocial, emotional, spiritual, environmental, and educational needs as outlined by the plan of care (POC).
• Collect data from the patient, family, significant other or other members of the interdisciplinary team and other health care professionals.
• Identify, interpret, and document assessment data collected in the nursing interview, physical assessment, and other health data.
• Document and report significant changes in condition or unusual incidents to appropriate IDT member such as client abuse/neglect, suicidal intent, harmful coping mechanisms or violence, etc.
• Collaborate with IDT and primary care provider to create HES for determination of hospice eligibility.
• Respond to patient and family needs or change in condition or need for acute patient intervention.
• Provide interventions, treatments, and pain management to patient and family to meet needs. Evaluate the effectiveness of pain management or other intervention and adjust to meet needs.
• Provide patient and family education on pain, symptom management, end of life, etc. Evaluate the effectiveness of education and adjust to meet needs.
• Formulate, implement, and revise individualized POC in collaboration with Interdisciplinary Team (IDT), patient, and family. The POC to include goals, pain management, interventions, education, discharge plan, etc.
• Develop reasonable and achievable outcome measures and establish priorities in the planning and provision of care.
• Read, understand, and follow the plan of care. Document interventions, outcomes, and changes in patient condition in electronic health record (EHR).
• Delegate visits to appropriate disciplines and manage visit sets.
• Oversee work of Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN).
• Participate in meetings to plan and evaluate patient/family services.
• Precept new staff and students.

Requirements

• ADN or BSN required
• Current, unrestricted Registered Nursing License in state of employment
• One-year nursing experience preferred
• Valid driver's license, auto insurance, and access to a reliable vehicle
• Must be at least 18 years of age
• Ability to develop, maintain, and apply knowledge of hospice and end-of-life process
• Ability to maintain professional boundaries with patients, families, and co-workers
• Ability to create and follow plans of care, and patient, family, and clinical staff directions
• Basic Microsoft Office skills
• Intermediate electronic health records skills; Epic preferred
• Ability to work effectively and cooperatively with others
• Ability to communicate effectively verbally and in writing
• Ability to be flexible in time and task to meet organizational needs
• Ability to maintain confidentiality about patients, families, caregivers, staff, donors, and organizational intellectual property
• Ability to use proper body mechanics, safe patient handling, and standard precautions

Agrace HospiceCare is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, basis of disability or any other federal, state or local protected class.