Facility: Wellstar West Georgia Medical Center

Overview
The RN Case Manager is responsible for providing and supervising primary care to approximately 25-35 patients in their home setting. This includes age appropriate interventions that meet physical, emotional, developmental, psychosocial and educational needs. The RN Case Manager is responsible for the coordination of all disciplines throughout the episode of care. The RN Case Manager communicates with all team members including RNs, LPNs, Therapists, Social Workers, Home Health Aides, the Physician, patient, family, and other internal or external individuals to ensure that the patient's plan of care is appropriately developed, implemented and that goals are met. The RN Case Manager supervises the LPNs and Home Health Aides throughout the patient plan of care. The RN Case Manager participates with leadership to develop and implement processes to continue improvement with patient and agency outcomes.
Responsibilities
Core Responsibilites and Essential Functions

DIRECT PATIENT CARE
• Assesses, coordinates with other disciplines and manages patient’s total needs, following physician’s orders, using the nursing process
• Develops patient’s plan of care coordinating with other disciplines
• Manages patient from admission through recerts to discharge and appropriately scheduling visits per physician’s order: adjust frequency as needed, based on patient clinical status and MD order
• Performs routine and complex nursing procedures to meet the need of the patient

COORDINATION OF SERVICES FOR EPISODE OF CARE
• Revises the plan of care based on patient need within physician orders, coordinating with other disciplines to ensure goals are met to achieve positive outcomes prior to discharge
• Supervises LPNs and Home Health Aides throughout the continuum of care.
• Develops and supervises the care plan provided to the Home Health Aides
• Reviews Plan of Care for patients with the Manager Home Health and other team members and support services
• Maintains communication with physician reporting any changes that may affect the patient’s recovery

PATIENT / CAREGIVER EDUCATION
Provides patient/caregiver education to develop and encourage self care to achieve positive outcomes
Utilizes both verbal and written tools to facilitate learning and promotion of independence during recovery
Be aware and report concerns to authorities or agency leadership on any issues that affect patient or staff safety

STAFF EDUCATION AND PROFESSIONAL DEVELOPMENT
• Participates in the orientation and education of new employees as appropriate
• Responsible for attending continuing education and in-services as directed and needed
• Responsible to remain current in clinical knowledge for the care of the home health patient
• Receives training, supervision or direction from leadership as needed

COMMUNICATION
• Communicates patient status changes and lab results to the physician as appropriate .
• Participates in care team conferences
• Responsible for checking voice mail box and staff messaging a minimum of once daily

REGULATORY GUIDELINES
• Demonstrates knowledge and appropriate application of CMS/State, and Joint Commission regulatory guidelines.
• Responsible for accurate completion of required OASIS and visit documentation in the patient’s EMR
• Completes all documentation within established timeframes

SUPPORTS AND PARTICIPATES IN PERFORMANCE IMPROVEMENT ACTIVITIES
• Participates in department performance improvement activities (i.e. chart review, committees, etc.).
• Participates in system-wide committees as requested.
• Identifies methods for improving department performance/care.
• Assists in implementing performance improvement opportunities

OTHER RESPONSIBILITIES
• Meets established productivity standards
• Weekend and call rotation as required
• Perform other duties as assigned by Home Health LeadershipRequired for All Jobs

Performs other duties as assigned

Complies with all WellStar Health System policies, standards of work, and code of conduct.

Qualifications
Required Minimum Education

Graduate of an approved school of professional nursing, Required

Required Minimum Experience

Minimum 1 year of Medical/Surgical Nursing Required and

Home Health, and ICU experience Preferred and

Must possess extremely strong critical care nursing skills.
Required

Required Minimum Skills

Strong critical care assessment and clinical skills required.

Positive leadership, problem solving skills, strong organizational and time management skills.

Strong communication (written and verbal) skills.

Ability to write and follow directions to patient’s homes.

Use of Windows based computer, utilizing home health patient software, email, internet, computer based learning modules, etc.

Good understanding of home health operations, reimbursement, law and regulatory processes.

OASIS knowledge preferred.

Required Minimum License(s) and Certification(s)

Reg Nurse (Single State) Required

RN - Multi-state Compact Required

Basic Life Support Required

BLS - Provisional Required

BLS - Instructor Required

Additional Licenses and Certifications