RN

Welcome Back Home Care, Inc.

Job Description

Job Title: RN Case Manager
Reports To: Clinical Director and Director of Professional Services
FLSA Status: Non-Exempt

Position Summary

The RN Case Manager assumes responsibility for a defined group of patients in their homes by providing comprehensive skilled nursing services, case management, and interdisciplinary coordination. The goal is to support each patient’s maximum rehabilitation and health outcomes, while maintaining strict compliance with federal, state, and local regulations governing home health services.

Essential Duties & Responsibilities

Patient Care & Case Management

• Regularly assesses and evaluates patients’ needs, medical necessity, and homebound status.
• Provides nursing care using the nursing process, including assessment, planning, intervention, and evaluation.
• Develops, updates, and implements individualized Plans of Care in collaboration with the interdisciplinary team.
• Documents discharge planning from initial visit and throughout the course of care.
• Ensures timely and thorough documentation of skilled nursing visits, care plans, medication profiles, change orders, summaries, and referrals.
• Conducts ongoing nursing assessments and communicates significant changes in condition to physicians and family members.
• Coordinates patient care with all disciplines and outside providers to ensure continuity of care.
• Conducts up to 30 field visit units per week, as assigned.

Documentation & Compliance

• Completes OASIS documentation within 48 hours and skilled nursing visit notes within 24 hours.
• Ensures all documentation supports medical necessity, homebound status, and compliance with Medicare and state regulations.
• Participates in chart audits, quality reviews, and Continuous Quality Improvement (CQI/QAPI) activities.
• Completes discharge audits within two weeks of discharge and ensures thorough Discharge Summaries and OASIS completion within 48 hours.
• Adheres to agency policies regarding comprehensive assessments, documentation timeframes, and data corrections.

Leadership & Team Collaboration

• Functions as the leader of a case management team, ensuring care meets professional standards.
• Assists the Clinical Director in conducting team meetings, case conferences, and scheduling.
• Reviews documentation of all disciplines for accuracy and consistency.
• Provides supervision, orientation, and teaching to RNs, LPNs, and CHHAs.
• Updates and reviews Home Health Aide care plans as needed.

Professional Standards

• Communicates effectively and courteously with staff, patients, families, and physicians.
• Maintains infection control standards and ensures safe handling of biohazards.
• Participates in on-call rotation as scheduled.
• Maintains competency in patient care skills through annual skills checklists and required in-services.
• Participates in the agency’s Compliance Program.
• Assumes responsibility for professional conduct, accountability, and adherence to Welcome Back Home Care values.

Education & Experience

• Current Registered Nurse (RN) license in the State of Oklahoma.
• Minimum of two (2) years of nursing experience preferred.
• One (1) year of home health nursing experience preferred.
• One (1) year of supervisory experience preferred.

Knowledge, Skills & Abilities

• Strong interpersonal and communication skills to interact effectively with patients, families, staff, and the medical community.
• Ability to analyze and assess patient care data to guide clinical decisions.
• Proficiency in the nursing process and application to home health care.
• Working knowledge of Medicare, Medicaid, and Oklahoma state home health regulations.
• Ability to use computers and electronic health record systems.
• Current CPR certification and compliance with personnel requirements as established by Human Resources.
• Demonstrated leadership, organizational, and time management skills.
• Ability to problem-solve, prioritize tasks, and work effectively in a fast-paced environment.

Physical Requirements

• Ability to work full-time (minimum 40 hours per week).
• Ability to sit, stand, walk, bend, stoop, and kneel as required.
• Ability to lift, push, or pull up to 75 pounds.
• Ability to drive within the agency’s service area and access patient homes.
• Ability to tolerate exposure to varied home environments and occasional unpleasant patient care activities.
• Adequate vision, dexterity, and hearing to perform documentation, operate equipment, and provide patient care.

Compliance Statement

All employees are expected to comply with Welcome Back Home Care, Inc. policies, state and federal regulations, HIPAA requirements, and ethical standards. Participation in the agency’s compliance and quality improvement programs is required as a condition of employment.

Equal Employment Opportunity (EEO) Statement

Welcome Back Home Care, Inc. is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex (including pregnancy, sexual orientation, gender identity), national origin, age, disability, veteran status, or any other protected category as defined by applicable law.

Education & Experience

• Current Registered Nurse (RN) license in the State of Oklahoma.
• Minimum of two (2) years of nursing experience preferred.
• One (1) year of home health nursing experience preferred.
• One (1) year of supervisory experience preferred.

Knowledge, Skills & Abilities

• Strong interpersonal and communication skills to interact effectively with patients, families, staff, and the medical community.
• Ability to analyze and assess patient care data to guide clinical decisions.
• Proficiency in the nursing process and application to home health care.
• Working knowledge of Medicare, Medicaid, and Oklahoma state home health regulations.
• Ability to use computers and electronic health record systems.
• Current CPR certification and compliance with personnel requirements as established by Human Resources.
• Demonstrated leadership, organizational, and time management skills.
• Ability to problem-solve, prioritize tasks, and work effectively in a fast-paced environment.

Physical Requirements

• Ability to work full-time (minimum 40 hours per week).
• Ability to sit, stand, walk, bend, stoop, and kneel as required.
• Ability to lift, push, or pull up to 75 pounds.
• Ability to drive within the agency’s service area and access patient homes.
• Ability to tolerate exposure to varied home environments and occasional unpleasant patient care activities.
• Adequate vision, dexterity, and hearing to perform documentation, operate equipment, and provide patient care.