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Beth Israel Lahey Health

Integrated health system delivering care, education

Hospice RN Case Manager

Nursing & Frontline Patient CareConfirmed live in the last 24 hours
Full-timePlymouth, MA, USA$37.14 - $82.22 /hr

About the Job

Requirements

  • Current Massachusetts professional Registered Nurse license.
  • Recent hospice case management or related home health experience is required.
  • Expertise in the electronic medical record (PTCT) and required hospice documentation.
  • Demonstrated ability to manage all aspects of terminal care, including expertise in pain and symptom management, intravenous and subcutaneous infusion, and knowledge of compounded medications.
  • Demonstrated ability to assess and respond to the needs of patients and families in a variety of settings.
  • Demonstrated customer service ability.
  • Valid Massachusetts driver's license and access to reliable transportation.
  • Ability to read, write, and speak English.
  • Comprehensive knowledge and skills in current end-of-life nursing practices.
  • Skill in interdisciplinary team-based care and the nursing process.
  • Ability to communicate effectively with people from a variety of backgrounds.
  • Ability to present in a self-assured, professional manner while functioning independently in a variety of settings.
  • Ability to sustain a positive attitude and personal connections despite continual personal and professional loss.
  • Ability to meet the physical requirements, including lifting, carrying, pushing, and pulling light to heavy equipment, objects, or supplies and transferring patients weighing 100 to 250 pounds.
  • Ability to meet the role's exposure and concentration demands, including potential exposure to blood, body fluids, and infectious materials.

Responsibilities

  • Provide care in accordance with hospice philosophy and articulate that philosophy.
  • Participate in an interdisciplinary team that includes the patient and family in developing a patient-specific plan of care driven by patient goals and preferences.
  • Serve as the physician's eyes and ears in the home or facility, communicate accurate assessments of patient condition to the physician, and offer expert guidance on treating end-of-life pain and other symptoms when requested.
  • Perform Registered Nurse pronouncements in all settings except the acute care hospital.
  • Conduct an initial assessment using established Local Coverage Determination guidelines to determine whether the patient meets hospice admission criteria.
  • Assess and document in the electronic medical record (PTCT) that the patient continues to meet hospice eligibility, using appropriate scales such as FAST and ECOG.
  • When hospice chaplain or social worker services are declined, gather information about psychological, social, and spiritual factors that may affect the plan of care, and seek input from other team members.
  • Provide skilled nursing services to meet needs identified in initial, comprehensive, and updated patient assessments.
  • Prepare and submit patient care plan updates for Interdisciplinary Group review at least every 14 days and before each recertification period.
  • Assume primary responsibility for coordinating and managing all aspects of the patient's plan of care.
  • Maintain communication with the attending physician, Hospice Medical Director, hospice pharmacists, Interdisciplinary Group members, hospice office staff, clinical supervisors and directors, and other agencies and facilities to coordinate care and resource use.
  • Consider safety, effectiveness, and cost when planning and delivering patient and family care.
  • Inform the Clinical Supervisor or Clinical Director proactively about unusual or potential problems.
  • Work with the pharmacist and primary care physician to use medications that are optimal and cost-effective.
  • Arrange medication delivery as ordered, accounting for differences among assisted living facilities, skilled nursing facilities, group homes, and private homes.
  • Educate patients, families, and contracted caregivers about medications and care processes to maximize patient comfort.
  • Document patient care issues, goals, and plans in the electronic medical record and export data for timely sharing with other clinicians.
  • Document in the electronic medical record according to agency standards to support accurate retrieval of quality indicators.
  • Meet routinely with staff in assisted living, skilled nursing facilities, and group homes to coordinate the plan of care.
  • Provide knowledgeable and respectful customer service to patients, families, and facilities, taking account of the patient's home environment and each setting's regulatory requirements and preferences.
  • Supervise Hospice Aide care at least every two weeks, including an annual face-to-face supervision.
  • Provide appropriate support at the time of death and offer bereavement support.
  • Maintain competency in end-of-life issues and pain and symptom management.
  • Participate in agency programs and community education as required to promote understanding and growth of hospice care.
  • Apply knowledge of agency policies, state regulations, Medicare Conditions of Participation, Joint Commission requirements, long-term care facility regulations, assisted living regulations, and end-of-life symptom-management algorithms.
  • Participate in in-service training and education with the goal of achieving Registered Nurse certification in Hospice and Palliative Care.
  • Participate in quality and performance improvement activities.
  • Perform other duties assigned by the Clinical Director.

Desired Qualifications

  • Baccalaureate degree in nursing from an NLN-accredited program.
  • Hospice and Palliative Care or Holistic Nursing certification.

About the Company

Beth Israel Lahey Health

Integrated health system delivering care, education

Beth Israel Lahey Health is an integrated health system that coordinates care across hospitals, clinics, and other care settings to keep patients connected wherever they are. Its services come from doctors, nurses, technicians, social workers, and educators who work together, guided by medical research and education. The system operates by linking hospitals, primary and specialty care, and support services so patients receive seamless care with access to resources like research-informed treatment and training for staff. Unlike standalone hospitals or fragmented care providers, it combines multiple facilities and care teams into a single network to improve consistency and efficiency. The overarching goal is to improve patient outcomes and experience by delivering high-quality, coordinated care through research-backed practices and continuous education for its workforce.

Company size
10,001+
Company stage
Not listed
Total funding
Not listed
Headquarters
Cambridge, MA
Founded
2017

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