RN Case Manager

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Job Summary: Provides skilled nursing care to patients in their home. Coordinate care with the interdisciplinary team, patient, family and referring agency, and assumes responsibility for the coordination of care. Provides service in accordance with the Agency philosophy, standards and policies.

Essential Functions:

• Initial and ongoing comprehensive assessments of the client’s needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time frames
• Preparing clinical assessment documentation and progress notes within the specified time frame of the Agency (Documentation note day of visit and SOC paperwork done within a 3-day period).
• Assesses patient’s condition, initiates plan of care, re-evaluates and updates as necessary
• Effectively communicates with ancillary and clinical staff to maintain consistency and continuity of patient care (Manages the care of the patient) conveys current information to the transferring facility including MAR and notification of transfer to the patient’s primary physician
• Ability to adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management
• Performs patient care responsibilities considering needs specific to the standard of care for the patient’s age
• Demonstrates knowledge of medications and their correct administration based on age of the patient and the patient’s clinical position
• Provides those services and/or treatments requiring substantial and specialized nursing skill
• Obtains all necessary physician orders and collaborates with the physician as the patient’s needs dictate
• Initiating appropriate preventive and rehabilitative nursing procedures
• Attends 80% of mandatory in-services and case conferences to discuss multidisciplinary team responsibilities and patient progress
• Follows up with obtaining lab results and notifying the physician of any significant results according to the Agency’s Policy and Procedures
• Re-evaluates the need for continued care on an ongoing basis; initiates recertification as necessary (every 60 days)
• Planning for discharge from the Agency with the patient and caregiver
• Promotes patient/family/caregiver education using various verbal and written communication techniques that take into account the patient’s/family’s cultural, ethnic, and/or personal needs or preferences
• Supervises Home Health Aides every other week according to state, federal, and agency
• Supervises Licensed Practical Nurses every 30 days according to state, federal, and agency regulations
• Initiates needed referrals to other disciplines and/or community resources
• Obtains needed supplies and equipment to provide care
• Knowledgeable of current federal, state, agency, and accreditation regulations concerning patient care
• Adheres to all Agency, payroll, billing, and documentation policies and procedures
• Admission of patient and complete the paperwork as defined per policy
• Schedules their staff and caseload effectively and manages the assignment of appropriate personnel for their client
• Provides evaluation for License Practicum Nurses and Home Health Aides on an annual basis

Professional Requirements:

• Adheres to dress code, appearance is neat and clean
• Completes annual education requirements
• Maintains regulatory requirements
• Maintains patient confidentiality at all times
• Reports to work on time and as scheduled, completes work within the designated time
• Attends annual review and department in-services, as scheduled
• Represents the organization in a positive and professional manner
• Actively participates in performance improvement and continuous quality improvement activities
• Complies with all organizational policies regarding ethical business practices
• Communicates the mission, ethics and goals of the organization
• Demonstrates effective time management and organizational skills; provides patient visits as scheduled; completes patient care within the designated time

Regulatory Requirements:

• Graduate of an accredited school of nursing
• Current state licensure as a Registered Nurse
• Two years of experience as a Registered Nurse preferably in a Home Health Care setting
• Current CPR certification, proof of Tuberculosis PPD given within the past 12 months, and Hepatitis consent/declination
• Valid state driver’s license and reliable automobile
• Proof of current automobile insurance
• Full command of verbal and written communication skills
• Demonstrate leadership capabilities, ability to relate well to staff and professionals

Language Skills:

• Ability to read and communicate effectively in English
• Additional languages preferred

Skills:

• Comprehensive knowledge of general nursing scope of practice and theory
• Basic computer skills
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care
• The ability to use durable medical equipment in the home

Physical Demands:

• Prolonged standing and walking required
• Requires working under stressful conditions to meet deadlines
• Identify patient needs, to make quick decisions
• Meet patient/family psycho-social needs
• Requires eye-hand coordination and manual dexterity
• Ability to utilize durable medical equipment in the home
• Ability to move up to 50 lbs. and patients

Job Type: Full-time

Pay: $80,000.00 - $85,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible schedule
• Health insurance
• Paid time off
• Vision insurance

Work Location: On the road