Job Description

Job Location: Spicewood - Austin, TX 78759
Position Type: 40 HRS - 1 FTE
Job Shift: M-F 8A-5PJOB TITLE:     Facilities RN Case Manager
DEPARTMENT: Clinical Services
REPORTS TO:   Team Leader
SUPERVISES:    none

POSITION SUMMARY:
The RN Case Manager provides and coordinates nursing care in the home care program and within various healthcare facilities, including assisted living facilities, personal care homes, skilled nursing facilities, and independent living facilities. The RN Case Manager is responsible for developing, maintaining, and supporting strong working relationships with these facilities to ensure seamless patient care and high-quality outcomes.
DUTIES AND RESPONSIBILITIES:
Facility-Based Nursing Care
- Provides direct patient care within assisted living facilities, personal care homes, skilled nursing facilities, and independent living facilities in coordination with facility staff.
- Conducts comprehensive nursing assessments, including vital signs, pain levels, breath sounds, and overall patient condition.
- Administers medications, treatments, and interventions in accordance with the individualized plan of care and facility policies.
- Ensures continuity of care by collaborating with facility nurses, administrators, and other healthcare providers.
Coordination of Care
- Acts as a liaison between patients, families, facility staff, physicians, and the hospice team to ensure clear communication and collaboration.
- Develops, maintains, and updates individualized care plans that align with hospice protocols and facility policies.
- Works with facility staff to prevent hospital readmissions by implementing proactive symptom management strategies.
Relationship Management
- Establishes and maintains strong professional relationships with facility administrators, nursing staff, and other interdisciplinary team members.
- Provides ongoing education and training to facility staff on hospice care principles, symptom management, and end-of-life care best practices.
- Attends facility staff meetings and care conferences to discuss patient needs, updates, and care planning.
Compliance & Documentation
- Ensures accurate and timely documentation in both hospice and facility records, adhering to regulatory and accreditation standards.
- Reports adverse events, falls, infections, and complaints to both facility leadership and the hospice team within required timeframes.
- Complies with all state and federal regulations governing hospice care within assisted living and skilled nursing environments.
Patient & Family Support
- Educates patients, families, and caregivers on disease progression, symptom management, and the hospice philosophy of care.
- Provides emotional and psychosocial support to patients, families, and caregivers within facility settings.
- Assists in advance care planning and goals-of-care discussions, ensuring that patient and family wishes are honored.

QualificationsQUALIFICATIONS:
- Graduation from an approved school of professional nursing as determined by the Board of Nurse Examiners.
- Unrestricted license as a Registered Nurse by the Texas Board of Nurse Examiners.
- Valid Texas driver’s license, auto liability insurance and safe driving record. (if required for the position)
- Knowledge of hospice federal and state regulations preferred.
- CPR certification.
- 1-year previous nursing experience.
- Strong computer skills including knowledge of and experience with Microsoft Office products and experience with electronic medical records (EMR).