RN Care Manager

  • SERVICE THE POSITION IS FOR: Keystone Medical Services
  • POSITION REPORTS TO: Keystone Clinical Manager
  • DEPARTMENT: 03 – Business Development
  • FLSA CATEGORY: Non-Exempt
  • WORKERS COMP CLASS: Nursing and Counseling – Outside of Nursing Home
  • EEO CATEGORY: Professionals

Job Description Summary

Work as a member of the Interdisciplinary team to assist patients and families in managing the psychosocial, emotional and resource needs related to life limiting illnesses.

Essential Job Functions

  1. 1.Initiates contacts with all Keystone patients living in home or assisted living environments as well as other patients/families as identified by the interdisciplinary care team.
  2. 2.Assesses the physical and emotional needs of patients/families/caregivers related to the patient’s life limiting illness and environment. Participates in development, implementation, evaluation and updating of interdisciplinary care plans.
  3. 3.Provides support and education for patients, families and community members regarding symptom management, disease process, patient needs, emotional and social aspects of life limiting illnesses.
  4. 4.Assists patients and families in identifying and utilizing appropriate resources to meet environmental, financial, legal or psychological needs.
  5. 5.Assists with directing patients and families to appropriate agencies to apply for SSI disability and Medicaid.
  6. 6.Participates in goals of care discussions with patients/families as needed for patients identified as hospice appropriate.
  7. 7.Assists with the completion of Advance Directives and facilitating referrals to outside agencies.
  8. 8.Collaborates/coordinates care between PCP and other specialists involved in patient’s care.
  9. 9.Assists with referral process and other administrative tasks as assigned.
  10. 10.Collaborates with other members of the Palliative Care interdisciplinary team (IDT) regarding patient needs/concerns and participates Palliative Care IDT team meetings.
  11. 11.Documents all patient/family contact and activity in an accurate, professional and timely manner.
  12. 12. Participates in community programs as requested to promote understanding of palliative care.
  13. 13.Participates in regular follow-up calls to Palliative Care patien
  14. 14.Operates within parameters of Keystone Medical Services and state, federal and other regulatory requirements.

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

All employees are required to comply with the policies and procedures of Hospice of Holland, Inc. and with all state, federal, and other regulatory requirements. They also comply with confidentiality laws as described in the Notice of Privacy Practices.

Job Qualifications:

Education and Experience

  1. 1.Education: Graduate of an accredited school of nursing and current licensure as an RN in the State of Michigan.
  2. 2.Experience: Two years of recent clinical experience. Previous Case/Care Management preferred.
  3. 3.Other: Current Michigan driver’s license and available transportation.

Skills and Knowledge:

    1. 1. Ability to work as part of an interdisciplinary team.
    2. 2.Ability to work proactively and be a self-starter.
    3. 3. Excellent communication and time management skills.
    4. 4. Ability to work comfortably with clients of various cultural and spiritual backgrounds.
    5. 5.Working knowledge of community resources.
    6. 6.Comfort with discussing Goals of Care.


Customer Focus – Making customers and their needs a primary focus of one’s actions; developing and sustaining productive customer relations.

Communication – Cleary conveying ideas and information through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

Managing Work – Effectively managing one’s time and resources to ensure that work is completed efficiently.

Decision Making – Identifying and understanding issues, problems and opportunities; comparing data from different sources top draw conclusions; using effective approaches for choosing a course of action of developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences.

Building Positive Working Relationships (Teamwork/Collaboration) – Developing and using collaborative relationships to facilitate the accomplishment of work goals.


Works under a general and somewhat removed control which manifests itself directly only on limited occasions. Such phases as planning and organizing the details of work and deciding the methods to achieve a given result are completely in the hands of the employee. The employee is expected to carry out not only all the ordinary duties of the position, but to meet unusual situations and provide proper interpretations without advice or instruction other than that afforded by the general plans, policies and procedures applicable to all work in the department or organization. Active control from a higher level is manifested only where matters of broad policy and coordination, long range plan, expenditure of funds and related items are involved. And even in such matters, the employee may participate by making recommendations, or developing ideas in conference with superiors. Actual contact between the employee and superior may be limited in terms of frequency and matters covered, when compared to the whole scope of the employee’s duties and responsibilities. They provide direction, set priorities and check the work of others through either direct supervision or as a content expert.

Physical Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities.

While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee must also be required to stand and walk. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust and focus.

Working Conditions:

The working conditions described here are representative of those encountered in the job. Specific conditions may be different than those described. Reasonable accommodations may be made to enable individuals with disabilities.

  1. 1.May be exposed to extremes of heat and cold in all weather conditions. Must drive in various weather conditions on roads in varying degrees of repair.
  2. 2. Subject to varying and unpredictable situations. Handles emergency or crisis situations. Travel required.
  3. 3. Ability to enter patient homes that are in various conditions.

Continuing Education Requirements:

Keystone personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor. In addition, Keystone personnel are expected to accept personal responsibility for other educational activities to enhance job-related skills and abilities.

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