U.S. Medical Management

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RN Case Manager

at U.S. Medical Management

Posted: 1/7/2020
Job Reference #: 1160003
Keywords: healthcare, patient

Job Description

RN Case Manager

Department:Comfort Hospice
Location:Houston, TX
Company:Comfort Hospice

Hospice RN Case Manager

$12,500 Sign-On Bonus/ $30k Retention Bonus over 5 years

U.S. Medical Management (USMM) is an affiliate of a leading Fortune 100 company. A national organization built on a continuum of care with premier healthcare providers, clinicians and patient focused individuals working together. Our Mission – “Through Compassionate Patient-Centered Care in the Home; We will Provide Exceptional Outcomes across our Continuum of Services” – Visiting Physicians Association, Pinnacle Senior Care, Grace Hospice, Comfort Hospice, Home DME & our In Home Health Assessments (IHA).

Our Values of Integrity, Respect, Teamwork & Excellence are leading us to a better tomorrow for patient care. Our Purposes Centered on “We are Unified in our Work through our Continuum of Services” “We can Find Comfort that We are Making a Difference for our Patients” & “We make a Broader Positive Impact on Society”, allows USMM to be poised for a phenomenal future.

We are seeking candidates who desire the experience of delivering quality & compassionate healthcare within proven care models with patients at the forefront of everything we do.

Some of the benefits and advantages of working with Comfort Hospice Include:       

  •  Grace/Comfort Hospice is CHAP accredited and we are Members of the National Hospice and Palliative Care Organization.    
  •  We invest in our employees’ career development and growth.     
    • Comprehensive orientation programs for new hires    
    • Leadership Academy meetings held off-site regularly for continuous development of our site leadership team members (Office Manager, CS, DCS, and Administrator).    
  •  Grace/Comfort Hospice offers advancement opportunities.    
    • Grace/Comfort Hospice has 25 locations across the U.S. and we are growing!  This growth creates additional advancement opportunities for strong performers.    
    • We provide an innovative healthcare environment offering a clinical ladder.     
  •  Grace/Comfort Hospice is founded firmly on five pillars of excellence: People, Service, Quality, Finance, and Growth.    
  •  Our environment offers collaboration and provides tools and programs to enhance our team’s ability to provide excellent care.     
    • Our point-of-care system is state of the art:  HomeCare HomeBase.     
    • Employees have access to referring physicians and other professional resources on a daily basis.     
    • Inter-disciplinary Team conferences are held regularly to discuss and optimize patient care.     
    • Our ‘Meaningful Memories’ program is in development to provide exceptional patient experiences. 


Position Description

Under the general supervision of the Administrator, the RN-Case Manager provides intermittent skilled nursing services; communicates the patient’s progress with other disciplines and directs, supervises and instructs nonprofessional hospice aide staff in the provision of personal care to the patient.


Essential Duties and Responsibilities

  • Under the Physician’s order, admits patients eligible for hospice services
  • Assess and evaluates patient needs/problems, identifies mutually agreed upon goals with patients
  • Reports patient status and need for other disciplines to agency intake coordinator, RN Manager and referring physician
  • Develops patient care plan that specifically addresses identified patient problems; nursing problems and goals.  Updates care plans on an ongoing basis; revises and resolves patient problems and goals as changes occur and/or recertification
  • Admit paperwork and patient care plan submitted to RN Manager within 2 days following the admit
  • Assures that all admit paperwork is completed in full at time of submission for timely data entry of IDG/POC information
  • Provides intermittent Skilled Nursing services including assessment, evaluation, procedures, teaching and training activities as outlined in the patient IDG Plan of Care
  • Provides Skilled Nursing visits according to visit schedule and notifies agency of need to alter schedule in any way
  • Reports significant findings to patient’s physician and RN Manager as they occur
  • Submits completed skilled nursing notes; communication notes and hospice aide supervisory notes per policy
  • Submits change orders within 48 hours of occurrence
  • Submits recertification paperwork by the due date provided by the RN Manager
  • Schedules an IDT meeting with assigned RN Manager to review patient’s needs, problems, level of care and any changes in Plan of Care for next cert period
  • Completes communication note documenting plans for recertification were discussed and agreed upon between the physician, patient, and RN Manager
  • Completes other required documents for recertification: new Medication Profile, updates Care Plan, and updates or completes new Hospice Aide Plan of Care, if applicable
  • Performs hospice aide supervisory visit at least q 2 weeks, and annually with hospice aide present
  • Effectively communicates with all members of the healthcare team
  • Acts as the patient’s advocate, and, as such, is a liaison to assist in communicating the patient’s needs to the multidisciplinary team
  • Supervises the hospice aide every 14 days
  • Provides direction and instruction as it relates to provision of personal care and related support services
  • Completes documentation on hospice aide supervisory notes
  • Reports identified performance related problems; patient complaints and/or deviation from the Hospice Aide instruction sheet to the RN Manage
  • Acts as a preceptor in the orientation of new nursing staff
  • Attends staff meetings and educational in-services per agency requirements
  • Continually strives to improve nursing care by broadening knowledge through formal education, attendance at workshops, conferences and participation in professional and related organizations and individual research reading
  • Obtains CEU’s as dictated by the State Board of Nurses
  • Attends at least 50% of the skilled nurse in-services and meetings provided by agency
  • Is responsible for obtaining information provided at skilled nurse in-services and meetings and demonstrates appropriate follow-up related to information given at meetings and in-services
  • Participates in PI program through submission of data collection as it relates to direct patient care problems and serving on PI teams
  • Follows agency policies and procedures
  • Participates in discharge planning process
  • Documents Discharge Planning beginning with admit and documents at least 2 weeks in advance instructions given related to discharge
  • Completes:          
    • Patient Care Plan
    • Discharge Nurse’s Note and submits them along with other notes turned in per agency policy


REQUIRED Knowledge, Skills and Experience

  • Is currently a Registered Nurse in the state of practice or in accordance with the Board of Nurse Examiners rules for Nurse Licensure Compact (NLC)
  • Ability to work in a field setting and exhibited ability to make sound nursing judgments
  • Ability to assess patient needs and formulate individualized patient care plans to meet those needs
  • Effective communication skills
  • Must have and maintain an automobile to be used for work


Preferred Knowledge, Skills and Experience

  • One year experience as a professional nurse