RN-Case 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

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  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.
• 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 DON and assumes responsibility to coordinate patient care for assigned caseload.
• Develops Home Health Aide Care Plan and supervises delivery of care and patient satisfaction of care. Makes changes to Care Plan as necessary.
• Reports directly to Director of Nursing or other nursing supervisor as assigned.

Communication

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  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.

Additional Duties

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  Participates in on-call duties as defined by the on-call policy and assigned by DON.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Instructs, supervises and evaluates home health aide care provided every 30 days.
• Attends in-service education as requested by DON.
• Other duties as assigned by DON.

Position Qualifications

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  Graduate of an accredited school of nursing.
• Possess and maintain licensure in state, CPR certification and valid driver’s license with automobile insurance.
• Responsible for supervising home health aides.
• Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.
• Able to tolerate prolonged or considerable walking or standing. Able to lift 25 pounds. Considerable reaching, stooping, bending, kneeling or crouching. Visual acuity and hearing to perform required nursing skills.
• Available during normal working hours 8:00am to 4:30pm Monday through Friday and understands on-call availability.