RN Case Manager-Hospice

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Location: Watertown, MA
Job ID: 176264-1A
Date Posted: Aug 10, 2022
Category: Nursing

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Job Description

Welcome To

Full-Time & Part-Time RNs are eligible to receive a Sign-On Bonus of up to $10,000 depending on location and hours worked!!

*Terms & Conditions apply - speak to a recruiter for details

Welcome to Lahey Health Continuing Care, part of Beth Israel Lahey Health. Our team provides ongoing care to individuals through our assisted living and skilled nursing facilities. Our teams of nurses, aides, food service, and environmental service employees work to create an environment that supports the physical, mental, emotional, and spiritual needs of our residents and patients, along with their families.

About the Job

Position Summary: The Hospice RNCase Manager plans and delivers care to patients utilizing the nursing process of assessment, planning, interventions, implementation, and evaluation; Effectively interacts with patients, significant others, and other interdisciplinary team members while maintaining standards of professional nursing and clinical competency.

Provides appropriate palliative and hospice care through assessment, teaching, counseling and direct care to client and/or family members. Coordinates care with other community resources as needed. Coordinates care with other team members and attends Hospice Interdisciplinary Team meetings as indicated

Key Relationships:
1. All other Clinical Positions: Work collaboratively in a multi-disciplinary team for quality patient outcomes.
2. Clinical Manager: Reports to – case conferences with on a weekly basis.
3. Office Support Staff: Work collaboratively to ensure accurate scheduling of pts visits, accurate insurance billing for services provided to pts.

On Call: Yes
Shift Rotation: Yes
Weekends: Yes

About Us

Beth Israel Lahey Health is dedicated to improving health and wellness and making a difference in the lives of our patients, their families and all members of the communities we serve.  Formed in March 2019, Beth Israel Lahey Health is a patient-centered, integrated care delivery system providing a continuum of services spanning academic, tertiary and community hospitals, dedicated orthopedic and psychiatric hospitals, primary and specialty care, community acute care, ambulatory care, behavioral services and home health.  

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.


Essential Duties & Responsibilities, including but not limited to: 

  • Manage care of patients, coordinate all services and facilitate communication between all providers.
  • Provide skilled nursing care and prescribed treatments to patients and families in their home.
  • Maintain productivity expectations.
  • Provide documentation of services utilizing problem-oriented record.
  • Plan for continuity of care with nursing team members, patient, family, and other disciplines.
  • Use opportunities for teaching nursing care, comfort measures and health practices to the patient, families and others.
  • Instruct and supervise care given by the Home Health Aides.
  • Communicate and coordinate with other health and social agency personnel to assist in planning, implementing, evaluation service to the patient and family.
  • Participate in bi-weekly hospice case conference or as required. 

Patient Care 

Assumes responsibility to coordinate patient care for assigned caseload including but not limited to:

  • Appropriate delegation to LPN staff, patient condition change visits, and completion of Hospice Item Set (HIS) time points. Accepts accountability for patient satisfaction scores and quality of care outcome measure results.
  • Completes and documents an initial assessment of patient and family to determine hospice care needs.  Provides a complete physical assessment and history of current and previous illness(es).Develops a patient specific plan of care, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and palliative nursing actions, with emphasis on pain and symptom management. Includes the patient and the family in the planning process.
  • Initiates the plan of care and makes necessary revisions as patient status and needs change.
  • Administers medications and treatments as prescribed by the physician.
  • Counsels the patient and family in meeting patient needs related to physical, emotional, and spiritual needs.
  • Respects and supports patient and family’s cultural beliefs and values, individual needs, health goals and treatment preferences.
  • Provides information to the patient and family regarding the dying process and expectations.
  • Provides instruction regarding medication actions, side effects, dosage, route, and frequency.
  • Instructs, supervises and evaluates hospice health aide care provided, Supervises the care provided by the hospice aide every two (2) weeks minimally, and as needed.
  • Manages the hospice benefit periods in accordance with evolving patient needs and continued eligibility for services.


  • Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
  • Attends and contributes to IDT meetings every two weeks at a minimum, and as needed.
  • Communicates and coordinates with the team LPN when delegating appropriate visits.
  • Collaborates, communicates, and cooperates as appropriate with other health care providers to ensure quality end-of-life care.


  • Demonstrates proficiency in HIS completion.
  • Documentation supports hospice eligibility.
  • Documentation supports that the patient meets hospice criteria ongoing.
  • Completes documentation in accordance with agency timeliness policies.

Professional Development

  • Maintains and updates clinical knowledge and skills based on current nursing practice.
  • Adheres to departmental requirements for required training.
  • Identifies specific learning needs & goals and collaborates with nursing leadership in developing a plan to meet them.

Additional Duties

  • Participates in the weekend/holiday/on-call rotation as defined by BILH at Home.
  • Ensures that arrangements for equipment and other necessary items and services are available.
  • Participates in in-service programs and supervises, teaches and precepts other nursing personnel as assigned by Clinical Manager.

Organizational Requirements:

  • Maintain strict adherence to the Continuing Care Confidentiality policy.
  • Incorporate Continuing Care Standards of Behavior and Guiding Principles into daily activities.
  • Comply with all Continuing Care Policies.
  • Comply with behavioral expectations of the Continuing Care Division.
  • Maintain courteous and effective interactions with colleagues and patients.
  • Demonstrate an understanding of the job description, performance expectations, and competency assessment.
  • Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
  • Participate in departmental and/or interdepartmental quality improvement activities. 
  • Participate in and successfully completes Mandatory Education.
  • Perform all other duties as needed or directed to meet the needs of the department.





Minimum Qualifications: 


  • Graduate of an accredited school of nursing. BSN preferred.

Licensure, Certification & Registration

  • Current license to practice as a registered professional nurse in the Commonwealth of Massachusetts.
  • Current Basic Life Support Certification
  • Valid Massachusetts driver’s license.


  • Minimum one year recent professional nursing experience required.

Skills, Knowledge & Abilities

  • Must be sensitive to the needs of terminally ill patients and families and one's own feelings about dying and death.
  • Must demonstrate the ability to interact in a positive and courteous manner with patients, families, other employees and outside vendors.
  • The ability to work both independently and as part of a team are essential.
  • Demonstrates excellent observation and problem solving/critical thinking skills.
  • Well-developed verbal and written communication skills; essential computer skills to work with EMR.
  • Self-directed and able to work with minimal supervision.
  • Shows strong ability to organize and prioritize workload independently; nursing skills per competency checklist.

Physical Requirements

Physical Requirements & Environment:

Mental and Visual Attention

  • The position requires a high degree of mental and visual concentration.

Physical Exertion

  • Weight
    • Nature of work requires lifting or moving medium weight (over 20 and up to 75 pounds).
  • Dexterity
    • Flow of work and nature of duties require high manual coordination.
  • Range of  Motion
    • Responsibilities require high range of motion.
  • Physical Conditions
    • Performance of duties requires remaining in position for prolonged periods of time.
  • Repetitive Motion
    • Responsibilities require frequent repetitive motion.

Working Conditions

  • Working conditions include continuous exposure to elements such as odor, noise, dust, chemicals, temperature extremes or airborne pathogens.

Exposure to Hazardous Materials

  • Performance of duties frequently involves exposure to hazardous materials.

Patient Care Conditions

  • Responsibilities entail exposure to blood and body fluids; standard precautions must be used.
  • Responsibilities include transporting, transfer and positioning of patients.
  • Incumbent must be continuously prepared to prevent a patient fall.

Sensory Requirements

  • Performance of duties requires the ability to discern and identify colors.
  • Performance of duties requires the ability to discern sharp from dull and hot from cold.
  • Performance of duties requires the ability to hear soft and loud noises.