Home Health RN

The Home Health RN Case Manager is responsible for coordinating and delivering skilled nursing care to patients in their homes. This position manages a caseload of patients, develops individualized plans of care, performs comprehensive assessments, coordinates interdisciplinary services, and ensures compliance with physician orders, agency policies, and regulatory requirements.

• Perform comprehensive patient assessments and develop individualized plans of care.
• Complete Start of Care (SOC), Resumption of Care (ROC), Recertification, Transfer, and Discharge assessments.
• Provide skilled nursing care in accordance with physician orders and agency policies.
• Monitor patient progress and update care plans as needed.
• Assess physical, emotional, psychosocial, and environmental needs of patients.
• Administer medications and treatments as ordered.
• Perform wound care, catheter care, infusion therapy, and other skilled nursing procedures.
• Identify changes in patient condition and communicate findings to physicians and appropriate care team members.

• Manage an assigned caseload of home health patients.
• Coordinate care among physicians, therapists, social workers, home health aides, and other healthcare providers.
• Ensure timely scheduling and completion of visits.
• Facilitate appropriate utilization of resources and services.
• Participate in case conferences and interdisciplinary team meetings.
• Monitor patient outcomes and work to reduce hospital readmissions.

• Complete all documentation accurately and timely within the EMR system.
• Ensure compliance with Medicare, Medicaid, state, federal, and accreditation requirements.
• Maintain accurate patient records and care plans.
• Complete OASIS assessments and documentation as required.
• Adhere to HIPAA and patient confidentiality requirements.

• Educate patients and caregivers regarding disease processes, medications, safety precautions, and self-management techniques.
• Provide instruction on equipment use and home safety.
• Promote patient independence and achievement of healthcare goals.

• Current Registered Nurse (RN) license in the applicable state.
• Graduate of an accredited school of nursing.
• Minimum of one (1) year of nursing experience.
• Valid driver's license, reliable transportation, and current auto insurance.
• Ability to travel throughout assigned service area.
• Strong assessment, organizational, and communication skills.
• Basic computer and EMR proficiency.