Home Care RN Case Manager

Job Title: Home Care RN Case Manager

Position Type: Exempt

Reports to: Clinical Practice Manager

GENERAL SUMMARY

Provides, coordinates, and directs the provision of home health nursing services and case management processes according to the assigned patient's individualized plan of care based on agency policies and procedures, through the competent application of nursing process. Case management services include monitoring patient care to ensure progress toward desired outcome, addressing patient and family needs. This position requires medications setup and oversight of medication reminders. It also takes into consideration levels of care using our Household Model.

PRINCIPLE DUTIES: 

• Performs patient comprehensive assessments and implement an individualized patient plan of care per physician orders that ensure quality and achieves desired outcomes and goals.
• Provides clinical episode management according to the organizational processes including oversight of patient's individualized plan of care and care plan changes as deemed necessary by patient's status or physician's ordered care.
• Utilizes a combination of agency resources and nationally recognized standards of practice to deliver high quality care and achieve excellent patient specific outcomes.
• Makes referrals to other disciplines as indicated by the patient's identified needs or documents rationale for not doing so.
• Promotes and maintains patient health and independence through teaching and appropriate rehabilitative measures, assisting patients in learning appropriate self-care techniques.
• Advocates and ensures patient participation in care planning and goals of care.
• Supervises caseload including Home Care Aides.
• Completes documentation timely, accurately, and at the point of care, according to regulatory requirements, SOC/Admissions, re-certifications, medication management, nurse visits, physician orders, care coordination etc.
• On- Call after hours for notifications only of changes or incidentals.
• Protects the home care agency by adhering to professional standards, home care policies and procedures, federal, state, and local requirements.
• Enhances service reputation by accepting ownership for accomplishing new and different requests;
• Exploring opportunities to add value to job accomplishments.
• Assists the resident in making doctor's appointments.
• Attends bi-weekly transitions meetings, Care Plan meetings.
• Participate in trainings of CNA's.
• Conduct CNA Annual Skills Check off.
• Performs specific work duties and responsibilities as assigned by Manager.

REQUIRED QUALIFICATIONS: 

• Current and unencumbered license to practice as a Registered Nurse (BSN preferred).
• One (1 ) year of clinical experience as a Registered Nurse (RN).
• Demonstrates knowledge of Home Care Federal/State rules and regulations.
• Valid Driver's License.
• Should have a reliable source of transportation.
• Basic Life Support Health Care Provider card through American Heart Association.
• Must be familiar with general use and functions of the computer, such as, usernames, password concepts, internet, email, navigation of computer desktop, including starting programs, using files, and windows, effective use of navigation buttons and tool bars.
• Ability to understand and follow instructions in English, communicate effectively with Members/Clients, family and staff.
• Ability to accurately document clinical information.
• Excellent assessment skills.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS:

Listening, manual dexterity, sitting, speaking, standing, walking, lifts up to 25lbs. I have read this job content and understand the information contained within the job description. I further understand that this job description is not intended to be or should be construed as an exhaustive list of all the responsibilities, skills, efforts or physical requirements/working conditions associated with this job. I may be required to perform additional duties as necessary to meet the standards and quality of care. This company is an equal opportunity employer.