RN HH Case Manager

Job Profile Summary
Travels across large geographic areas with no set patient schedule to provide necessary health-care services for patients requiring Home Health, Infusion and Pediatric nursing, and/or Palliative and Hospice services in their homes. Evaluates and executes appropriate treatment for referred patients with emphasis on quality of care, continuity of services, and cost-effectiveness. Conducts initial assessment and establishes a plan of care for patients and provides direct patient care.
Job Description Major Responsibilities:
Assumes responsibility for workload consisting of patients requiring Home Health, Infusion and Pediatric nursing, and/or Palliative and Hospice services.
Conducts initial assessment to obtain thorough physical, social and environmental data. Establishes the plan of care in accordance with the physician orders and patient needs. Provides direct patient care and adjusts nursing care processes as needed. Identifies problems, modifies nursing care plan, and evaluates outcomes within an appropriate time frame. Advises and consults with family and other personnel, as appropriate.
Provides on-going assessment of patient response to treatments and teaching and applies interventions as appropriate. Updates and revises plan of care as indicated.
Completes documentation including visit assessment, OASIS, 485 and verbal orders accurately and promptly and within the standards.
Communicates with physicians to confirm and update patients' plan of care. Provides status updates and ensures ongoing communication with the physician and other members of the health care team.
Facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge. Participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate.
Participates in chart audits and continuous quality improvement activities as requested. Identifies, develops and participates in process improvement opportunities that will enhance the quality of the services provided.
Maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines.
Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the department's policies and procedures. Age-specific information is developed further in the departmental job standards.
Licensure, Registration, and/or Certification Required:
Registered Nurse license issued by the state in which the team member practices, and Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required, and
A valid drivers license issued by the Division of Motor Vehicles.
Education Required:
Associate's Degree in Nursing.
Experience Required:
Typically requires 3 years of experience in clinical nursing.
Knowledge, Skills & Abilities Required:
Demonstrated competency in Home Health, Infusion and Pediatric nursing, Palliative and Hospice.
Excellent communication skills. Strong interpersonal skills and the ability to work with a variety of clients with patience and respect. Good organizational, analytical and problem solving skills.
Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.
Proficiency in clinical skills with the ability to work under direction and make sound judgments.
Ability to operate the necessary equipment to perform the job, i.e., FAX, computer, copier, telephone system.
Ability to assess data reflecting the patient's status and the ability to interpret the appropriate information needed to identify each patient's requirements relative to their specific needs.
Must have a tolerance for differences and an appreciation of multi-culturalism and diversity of the patients and their families.
Must possess and provide proof of a valid Driver License and a registered, functional car with adequate insurance coverage.
Physical Requirements and Working Conditions:
Must be capable of the manual dexterity required to use and operate a variety of equipment.
Must have the physical ability to move about in confined spaces, including bending, twisting, kneeling, squatting and occasionally reaching one or both arm overhead.
Must be able to work safely with people of various sizes and weight with diverse and complex medical conditions and physical limitations.
Must be able to sit, stand, walk and climb stairs for limited to prolonged periods of time to complete required paperwork, gain entry to patients' residences, travel from assigned visits and attend a variety of work related activities.
Must have the physical stamina to attend to patient care requirements over a period of three or more hours without complete rest.
Must have accurate vision to read gauges and measuring devices and to interpret written instructions.
Subject to extreme temperature changes due to weather conditions.
Subject to exposure to chemical and hazardous waste and communicable disease.
Must be able to:
Lift up to 50 lbs from floor to waist.
Lift up to 20 lbs from waist to overhead.
Lift and carry up to 40 lbs. at waist height reasonable distance.
Must be able to:
Push/pull with 30 lbs. of force.
Perform a sliding transfer of 150 lbs. with a second person present.
This job description indicates the general nature and level of work expected of the incumbent. It is not
designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.



CUSTOM FIELDS Primary Home Unit
516505239109-Burlington Walworth - Hospice-WI System Affiliates SimpliFi Job Status Shift
8hr Day Shift (40) Shift Information
1st shift from 8am to about 4:30pm Monday through Friday SimpliFi Clinical Interviewing- Yes/No
No On Call, Call Back Requirements
No Weekend Rotation
No Holiday Requirements
No Floating Requirements
Within the community to patient homes Patient Service Area (PSA) DNU
System Affiliates JOB SUMMARY CH Home Burlington Walworth -... JOB DESCRIPTION

RN Case Manager Home Health - Burlington / Walworth

Unit Information:

o Beds: NA

Census? Average patients/day? 105

o Minimum Years of Experience required? 2 years

o Will you accept a first-time traveler? Prefer experience

Patient Types/Common Diagnoses: End stage

o Home Hospice with home, ALF, SNF, group home, independent living, and 2 Hospitals for GIP, End Stage patients

Patient Ratios:

o RN: 7 RNCM with caseloads 14-16 per RN

o LPN (if applicable):NA

o CNA: 6

Required License, National Certification, Certs:

o BLS, Driver's license, auto insurance,

Skills required:

o RN

Support within the Department:

o NA

Technology/Equipment:

o EMR: Epic and Rover

o IV Pump: Yes

o Med dispensing: Yes

o Monitors: chair and bed alarm

o Unit specific equipment: home health supplies with bag and trunk supplies

Floating: If yes, where?

o Within the community to patient homes

Orientation (facility and unit):

o How many days of unit orientation? 1 week

Scheduling:

o Weekend rotation: NO

o On call? If so, what is that schedule? NO

o Holiday Expectations: NO

o Should approval of RTO go through manager or will you allow the interviewing team (if applicable) to approve time off on your behalf? Yes

o Shift times: 1st shift from 8am to about 4:30pm Monday through Friday

Other notes:

o Scrub Color: Blue or black

o Parking: Free? At the Burlington and Walworth office is free

o Unit Culture: Teamwork and team support


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