RN Case Manager

Job Title/Position: Registered Nurse (RN)

Reports To: Clinical Manager

Job Description Summary

The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

Essential Job Functions/Responsibilities

Patient Care

• Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).

• Regularly re-evaluates patient nursing needs.

• Initiates the plan of care and makes necessary revisions as patient status and needs change.

• Uses health assessment data to determine nursing diagnosis.

• Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.

• Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician. Provides direct patient care as defined in the State Nurse Practice Act.

• Counsels the patient and family in meeting nursing and related needs.

• Provides health care instructions to the patient as appropriate per assessment and plan of care.

• Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.

• Acts as Case Manager when assigned by Clinical Manager and assumes responsibility to coordinate patient care for assigned caseload.

Communication

• Prepares clinical notes and updates the primary physician when necessary and at least every 60 days.

• 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.

• Communicates with community health related persons to coordinate the care plan.

• Participates meaningfully in all team meetings aimed at continuity of care, or care conferences.

Additional Duties

• Participates in on-call duties as defined by the on-call policy and patient census.

• Ensures that arrangements for equipment and other necessary items and services are available prior to making home visits.

• Instructs, supervises and evaluates home health aide care provided every two (2) weeks.

• Instructs, supervises and evaluate the Licensed Practical Nurse every 30 days.

• Attends and participates in all mandatory staff meetings, and educational opportunities including in-services.

• Assist with onboarding and orientation of new team members as assigned.

• Other duties as assigned.

Position Qualifications

• Must be a graduate of an accredited school of nursing.

• Must have One (1) to two (2) years of acute care experience in an institutional setting, or Two (2) - Five (5) years of home care experience.

• Current licensure in state (able to obtain MN licensure prior to hire)

• Current (or current prior to hire) BLS certification.

• Associates degree, with one (1) year of home health care experience Required, Bachelors degree preferred.

• Management experience not required. Responsible for supervising home health aides.

• Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.

• Must have GRIT and INTEGRITY.

• Prolonged or considerable walking or standing. Able to lift, position or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling or crouching. Visual acuity and hearing to perform required nursing skills.

• Licensed driver with automobile that is in good working order and insured in accordance with the organization requirements.