RN Case Manager - Hospice - Full Time - Santa Cruz County

Bridge Home Health & Hospice Santa Cruz, CA, US

Apply Now

$60 - $64 / hour

Apply Now

Req #573

Job Description Summary

The Registered Nurse Case Manager plans, organizes and directs care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

Essential Job Functions/Responsibilities

Patient Care:

Completes an initial, comprehensive, and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es).
Provides professional nursing care by utilizing all elements of nursing process and as defined in the state Nurse Practice Act.
Assesses and evaluates patient’s status by writing and initiating plan of care.
Writing and initiating plan of care
Regularly re-evaluating patient and family/caregiver needs
Participating in revising the plan of care as necessary
Initiates the plan of care and makes necessary revisions as patient status and needs change.
Uses health assessment data to determine nursing diagnosis.
Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process.
Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
Counsels the patient and family in meeting nursing and related needs.
Provides health care instructions to the patient as appropriate per assessment and plan.
Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self- sufficiency and optional comfort care.
Maintain current documentation on EMR system according to organization policies/procedures and applicable laws/regulations.
The RN Case Manager, when assigned by the Clinical Manager/DPCS, assumes responsibility to coordinate patient care for an assigned case load.
The Admission RN may act as Case Manager when assigned by Clinical Manager/DPCS and assumes responsibility to coordinate patient care for assigned caseload.
The RN Case Manager may act as an Admission Nurse when assigned by Clinical Manager/DPCS and assumes responsibility to coordinate with intake, program staff and management to complete a patient initial admission/assessment with plan of care.

Communication:

Completes, maintains, and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.
Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
Communicates with community health related persons to coordinate the care plan.
Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group.
Provides and maintains a safe environment for the patient.
Assists the patient and family/caregiver and other team members in providing continuity of care.
Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.
Attends interdisciplinary group meetings.

Additional Duties:

Participates in on-call duties as defined by the on-call policy.
Ensures that arrangements for equipment and other necessary items and services are available.
Supervises ancillary personnel and delegates responsibilities when required.
Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and Inservice classes.
Fulfills the obligation of requested and/or accepted case assignments.
Actively participates in quality assessment performance improvement teams and activities.
Must adhere to the company attendance and reliability guidelines, which are an essential function of the job to ensure quality, and consistent patient care.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbent(s) of this job. The incumbent(s) may be requested to perform job related tasks other than those stated in the description

Job Qualifications:

A graduate of a National League of Nursing accredited school of nursing.
Current licensure in state of practice and current CPR certification.
Must possess a valid California Driver’s License and can show proof of valid auto insurance.

California only:

May have an RN license and practiced as an RN for a minimum of one year with prior LVN experience in public health, home care, Hospice, Hospital or Skilled nursing facility.

All States:

Registered nurses shall have a minimum of (a) one (1) year of experience as a professional nurse within the last three (3) years OR (b) have a baccalaureate degree in nursing from a program accredited by the National League for Nursing and a current RN license. A minimum of two years’ experience, at least one of which is in public health, home care, or hospice nursing is preferred.
Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order.
Management experience not required. Responsible for supervising hospice aides.
Self-directed and able to work with minimal supervision.
Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.
Prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stop bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills.

Physical Requirements:

The ability to sit occasionally for 1-3 hours.
The ability to frequently stand for 3-6 hours.
The ability to occasionally drive/ operate foot control for 1-3 hours
The ability to walk intermittently on level and or unlevel surface for less than 1 hour
The ability to intermittently bend or climb for less than 1 hour.
The ability to occasionally twist, kneel, crouch and crawl for 1-3 hours
The ability to lift 50 pounds frequently for 3-6 hours
The ability to lift greater than 50 pounds occasionally for 1-3 hours.
The ability to carry up to 50 pounds frequently for 3-6 hours.
The ability to carry greater than 50 pounds occasionally for 1-3 hours.
The ability to push up to 50 pounds frequently for 3-6 hours.
The ability to push greater than 50 pounds occasionally for 1-3 hours.
The ability to pull up to 50 pounds frequently for 3-6 hours
The ability to pull greater than 50 pounds occasionally for 1-3 hours.

Share this job

Related Jobs

Home Health

Full-time

2 days ago

Home Health Field Registered Nurse (RN)

21st Century Home Health Services Cupertino, CA

$130,000 - $160,000 / year

At 21st Century Home Health Services (21HHS) , we treat every patient with the same empathy, compassion, and understanding we would show our own family. With more than 600 employees, we are the largest home health agency in San Francisco and the fastest-growing in the Bay Area. Today, we care for more than 4,000 patients across San Francisco, San Mateo, Santa Clara, Santa Cruz, Alameda, Contra Costa, Solano, Napa, Yolo, Placer, El Dorado, and Sacramento counties—and we are actively expanding into Marin and Sonoma counties. Our clinicians are dedicated not only to the patients they serve, but also to one another. The results speak for themselves: hospital readmission rates at 21HHS consistently remain under 10%, compared to an industry average of over 15%. We’ve also set a new benchmark for employee satisfaction in home health. Recognized as a 2024 Top Workplace, 21HHS fosters an environment of support, growth, and recognition through open communication and professional development opportunities. Key achievements include: San Francisco Chronicle Top Workplaces in the Bay Area : Ranked 3rd among all medium-sized companies and 1st among home health agencies. National Recognition : Ranked 12th among medium-sized healthcare companies nationwide and 1st among home health agencies. Patient and employee feedback on Yelp, Google, Glassdoor, and Indeed further validates our commitment to quality care and workplace excellence. By prioritizing engagement and satisfaction, 21HHS attracts top clinical talent and delivers outstanding outcomes, cementing our place as a leader in home health. Please note: All opportunities at 21HHS require being in the field visiting patients in their homes. \n DUTIES AND RESPONSIBILITIES Providing hands-on patient care including, but not limited to (must be within RN license scope): PICC lines, Wound Vacs & Care ,Kangaroo & feeding Pumps, Management of NG, G, and J tubes, Staple & suture removal ,Drains such as, JP, Biliary, Nephrostomy, ,Foley/suprapubic catheters (insertion, removal, and troubleshooting), PleurX drainage system ,Trach care, Blood draws, Ostomy management ,SQ and IM injections, IV antibiotic/TPN administration and Compression wraps. Provides direct patient care as defined in the state Nurse Practice Act Implements a plan of care initiated and directed by the Case Management Registered Nurse Provides accurate and timely documentation within 24-48 hours consistent with the plan of care Assesses and provides patient and family/caregiver education and information pertinent to diagnosis and plan of care Assists the registered nurse in performing skilled needs procedures and duties, which include preparing equipment and materials for treatments and assisting the patient in learning appropriate self-care techniques Participates in coordination of home health services, appropriately reporting the identified needs for other disciplines (HHA, OT, PT, MSW, ST) to the Case Management RN or other disciplines Uses equipment and supplies effectively and efficiently Participates in personal and professional growth and development Performs other duties as assigned by the Case Management Registered Nurse Retrieves communication on assigned patients. Uses information received as a basis for establishing priorities of care Gives a timely and pertinent report to the Case Manager Records pertinent and concise information that will reflect the patients' needs, problems, capabilities and limitations, as well as the patients' response to nursing interventions Entries will accurately record any incident that has a bearing on the patient. Reports pertinent information timely to the Case Management Registered Nurse and to Provider Attends weekly Case Conferences as required to coordinate and communicate information regarding patient care and treatment Ensures patient privacy in maintaining medical records and when providing care. Maintains professionalism and seeks opportunities to enhance knowledge of clinical skills Maintains productivity standards as directed by the Case Management Registered Nurse . Completes and reviews Start of Care assessments, documentation, and plans of care with Case Manager, as needed. Participates in on-call duties as required by weekend rotation Job Specifications One (1) year of recent nursing experience Experience requirement may be waived for internal candidates and/or new grad posting. One year of home health care experience is preferred. Experience with high acuity patients is a plus Experience working with an interdisciplinary team is highly desired Graduate of an accredited school of nursing (Bachelor's degree) Current CA Registered Nurse License (RN) Current Basic Life Support (BLS) Card Valid CA Drivers License with acceptable driving record All license and certifications must be current at time of hire and sustained throughout employment Self- directed, Critical Thinker, Outstanding interpersonal skills, Organized, Computer literacy. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist. Must maintain current with annual compliance training and certifications \n $130,000 - $160,000 a year \n 21st Century is an equal opportunity employer, committed to fostering a diverse and inclusive workplace. We strictly prohibit discrimination or harassment of any kind, including but not limited to race, color, sex, religion, sexual orientation, gender identity, national origin, disability, genetic information, pregnancy, or any other characteristic protected under federal, state, or local law.

Full-time

2 months ago

REGISTERED NURSE

Skyline Healthcare Center-San Jose San Jose, CA

SUMMARY-Registered Nurse-RN Assesses and evaluates the health status of resident / patient and provides care and treatment in accordance with physician orders and standards of practice. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned. Assesses patients by physical examination including pertinent diagnostic testing to determine health status. Administers medications and treatments. Participates in the care planning process and oversees implementation of the plan. Supervises LPNs and nursing assistants. Communicates with physicians regarding changes in conditions, diagnostic test results, etc. Documents assessments and care in compliance with standards of care and company policy. Educates patients and their families on health-related issues. ENTRY QUALIFICATIONS Graduate of an accredited school of Nursing. Valid State licensure as an RN. Current CPR certification. SUPERVISORY RESPONSIBILITIES Supervises LPNs, LVNs, student nurses, nurse assistants Benefits Paid Time Off -Vacation, Sick pay, Holiday, Jury Duty, Bereavement Leave. Health Benefits- Medical, Dental, Vision, Flexible Spending Accounts, Life Insurance. Retirement- 401(k) Plan

Part-time

2 months ago

RN Case Manager

Anchor Health Cupertino, CA

***SIGN ON BONUS*** Are you looking for a work place where you can make a genuine difference? Company Culture that feels supportive, genuine and appreciative of all? Anchor Health is committed to the communities of which we serve, the patients and families we have the honor of caring for and the EMPLOYEES who have chosen us as their work family. Anchor Health is a unique organization that offers enhanced hospice services throughout San Mateo County. We are currently seeking an experienced hospice RN Case Manager to join our team. Duties of Hospice Registered Nurse Include: Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness. Conducts home visits and assesses/evaluates patient's status. Initiates the plan of care and makes necessary revisions as patient status and needs change. Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process. Administers medications and treatments as prescribed by the physician. Attends and participates in Interdisciplinary Group Meetings. Completes, maintains and submits accurate and relevant clinical notes regarding patient's condition and care given. Supervises ancillary personnel and delegates responsibilities when required. Qualifications: Graduate of accredited school of nursing Current RN license in California Current CPR Certificate Registered nurses shall have a minimum of (a) one year of experience as a professional nurse within the last three years OR (b) have a baccalaureate degree in nursing from a program accredited by the National League for Nursing and current RN license. Minimum of two years experience, at least one of which is in the area of public, home care, or hospice nursing. Must have a valid CA driver license and an automobile that is insured in accordance with the requirements of state of California and is in good working order. Excellent observation, verbal and written communication skills and nursing skills per competency checklist. Job Types: Part-time

MDS

Full-time

2 months ago

Medicare MDS Coordinator RN (Registered Nurse)

Cupertino Healthcare & Wellness Center Cupertino, CA

Under the direction and supervision of the Director of Nursing Services, the Medicare/MDS Coordinator is responsible for notifying and coordinating the Interdisciplinary Team (IDT) for MDS assessment completion in accordance with State and Federal regulations. Medicare MDS Coordinator QUALIFICATIONS • Current licensure in nursing. RN required. • Written and verbal communications skills in English as business necessity. • Administrative and organizational ability and skills. • Current certification in CPR preferred. • Two years nursing experience in long term care preferred. • Supervisory experience preferred. Medicare MDS Coordinator GENERAL DUTIES AND RESPONSIBILITIES: CLINICAL • Coordinates the Medicare/MDS resident assessment process. • Ensures the Interdisciplinary Team completes the MDS Assessment in a timely manner. • Coordinates development, implementation and evaluation of plan of care. • Coordinates and performs, administers or implements as needed treatments, medications or other nursing interventions as indicated by the resident plan of care or as ordered by the physician. • Coordinates and provides as needed nursing care in accordance with infection control standards. • Follows safety policies in performing nursing care. • Coordinates and initiates as needed emergency measures according to center policy and within standards of nursing practice. Medicare MDS Coordinator ADMINISTRATIVE • Ensures the exchange and use of essential information necessary for quality resident care. • Ensures all documentation is maintained as required by Federal and State regulations and Company policy. • Coordinates and/or participates in all assigned meetings and inservices. CONSUMER SERVICE • Presents professional image to consumers through attire, behavior and speech. • Adheres to Company standards for resolving consumer concerns. • Ensures that all residents/residents’ rights are protected.

Full-time

2 months ago

Staff Nurse RN (Registered Nurse)

Cupertino Healthcare & Wellness Center Cupertino, CA

Sign-on Bonus $2,500.00 Staff Nurse RN (Registered Nurse) is a licensed professional nurse directly under the supervision of the Director of Nursing Services that provides care and services to residents in a long-term care setting. Staff Nurse RN (Registered Nurse) Qualifications: • Graduate of an accredited RN school of nursing. • Current nursing license, in good standing with the State licensing board • Strong qualities of leadership, communication, and organizational skills. (moved below) Ability to provide quality patient care in accordance with applicable standards, policies, and procedures. • Possess critical thinking skills to analyze, synthesize, and evaluate clinical data and observations in developing a nursing plan of care. • Comprehensive knowledge of applicable nursing principles and practices to ensure the quality of care standards for resident’s care. • Possess the willingness to work with professional and nonprofessional personnel. Proficiency in the English language including the ability to speak, read, write, and comprehend the language with minimal to no difficulty. • Valid CPR certification Staff Nurse RN (Registered Nurse) General Duties and Responsibilities: GENERAL • Provides nursing care as prescribed by physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, policies, and procedures • Administers professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being utilizing the nursing process of assessing, planning, implementing, and evaluating patient care CLINICAL • Admits, transfers, and discharges residents in accordance with policy and procedure • Orients new residents/families as necessary • Gives/receives nursing reports upon beginning and ending of assigned shift. Reviews daily patient reports and assignments with Nursing Assistants upon the beginning of the assigned shift. • Assures that the unit area is maintained in a clean and safe manner for resident comfort and convenience. • Conducts daily resident rounds to assess and evaluate the resident’s physical, medical and emotional status and to implement or revise nursing interventions to the resident plan of care. • Records care information accurately, timely and concisely. Completes all required documentation including resident assessments, interventions, and patient response(s) in the medical record in accordance with policy. • Initiates, reviews, revises, and updates resident Plans of Care as indicated. Evaluates the patient’s progress toward specific goals and adjusts the nursing plan of care, as necessary. Receives and transcribe orders accurately from attending/alternate physician • Receive and transcribe orders accurately from attending/alternate physician • Assists in making rounds with the attending physician, as necessary. • Prepares / administers medications as ordered by the physician and within the legal scope of practice. • Completes medical treatments as indicated and ordered by the physician. • Evaluates resident response and reports adverse reactions to medications or treatments in accordance with the policy. • Assures that narcotic and controlled drugs are secure, inventory counts are accurate and narcotic register documentation is timely and accurate • Orders prescribed medications, supplies and equipment as established by the facility’s policies and procedures. • Requisitions and arranges for diagnostic and therapeutic services as ordered by the physician. • Informs the RN Supervisor or RN in charge of the facility and others as appropriate of resident status and related matters • Attends various facility meetings (care conferences, stand-up meetings, staff meetings, Medicare meetings, discharge plan meetings, etc.) as required. • Reports allegations of abuse or unusual occurrence per State and Federal Regulations and facility policy. Assists with a gathering of information relative to the event. • Initiates emergency procedures (including basic CPR) and provide emergency patient treatments • Participates in the facility’s infection control program for monitoring communicable and/or infectious disease among residents and staff. • Participate in procedures for reporting hazardous conditions or equipment. • Assists in orientation of newly assigned personnel as requested. • Assumes Charge responsibility following orientation period as requested. • Performs other position-related duties as assigned. • Supervise CNAs SUPERVISION • Make resident rounds to ensure appropriate care is being rendered, identifying, and making corrections as necessary. • Meet with nursing personnel to assist in identifying and correcting problem areas and/or the improvement of resident care. • Assist the Charge Nurse in revision and distribution of nursing assignments as needed. • Assist in the supervision and direction of nursing personnel. • Participate in disciplinary action and evaluation of nursing personnel. CONSUMER SERVICE • Presents a professional image to consumers through dress, behavior, and speech. • Treats residents/family members with dignity and respect • Responds to Resident and family concern(s) and assists in resolving grievances. Records grievances per facility policy Staff Nurse RN (Registered Nurse) ADDITIONAL DUTIES • Participate in the facility's Quality Assurance (QA) program as requested or needed. Assist in correcting findings and deficiencies from the Department of Health Services, Consultants, and the Quality Assurance Team as directed by the Director of Nursing. Actively participates in Quality Assurance Performance Improvement teams and activities • Ensures the protection of health information as required by the Health Insurance Portability and Accountability Act (HIPAA)