RN Case Manager

Position Summary

Provides direct care and case management for a team of Agency clients in accordance with the State Nurse Practice Act, Federal Regulations, State Rules, and Agency policy.

Organizes required supplies and documentation required for each home visit.

Schedules patient home visits in accordance with the physician Plan of Care.

Submits future schedule of planned home visits to Nursing Supervisor per agency guidelines.

Directs: Assigned team members of RNs, LPNs, Home Health Aides, and Personal Care Assistants.

Qualifications

Graduate of a school of professional nursing.

Current license as a Registered Nurse in the state(s) of practice. Baccalaureate degree preferred.

Minimum of two (2) years of nursing experience. Home care experience preferred.

Ability to supervise and direct members of client care team.

Demonstrated strong and effective written and verbal communication skills and good interpersonal skills.

Ability to deal tactfully with clients and the community.

Demonstrated organizational and time management skills.

Knowledge of home health regulatory and reimbursement requirements preferred.

Licensed driver with automobile insured in accordance with state and/or Agency requirements and in good repair.

Essential Functions/Areas of Accountability

1. Reviews client referral information and responds to requests and inquiries as appropriate.

• Collaborates with clinical supervisor regarding the eligibility and appropriateness of client for home care services.
• Completes comprehensive assessments including OASIS data set within forty-eight (48) hours of referral for home health care unless other arrangements are made.
• Determines appropriateness of referral for home care services and responds per Agency policy and standard guidelines.

2. Performs initial and ongoing client assessments based on Agency policy and standards of practice to ensure effective and appropriate home care services.

• Performs comprehensive assessments including OASIS data collection where indicated.
• Performs comprehensive assessments including OASIS data collection where indicated.
• Considers the physical, psychological, and socioeconomic needs of the client, the level of family acceptance, and the ability for client needs to be met in the home.
• Collaborates with physicians, other health care professionals (therapists, social services, pastoral care, & supportive services), clients, and families in developing a comprehensive, coordinated plan for care.

3. Directs, plans, and initiates appropriate action independently and responsively in home care situations.

• Identifies and assesses overt and subtle signs of impending physiologic and psychological changes. Notifies the physician in accordance with Agency policies and procedures.
• Makes decisions and/or recommendations reflecting consideration of immediate and long-range effects (frequency of visits, components of care plan, additional services).
• Confers with the clinical supervisor on a regular basis. Utilizes agency and community resources appropriately.
• Completes documentation for the patient’s clinical record in a timely manner in accordance with all regulations and agency policy.
• Monitors documentation of clinical records to ensure compliance with regulatory standards of timeliness, accuracy, and completeness.
• Provides on-call support for clients per schedule.
• Communicates with other disciplines/departments when required.

4. Manages/supervises a team of RNs, LPNs, and Home Health Aides to provide effective and quality home care services.

• Identifies the educational needs of team members.
• Identifies the educational needs of team members. Provides training or refers to clinical supervisor to arrange specific training program. Provides or recommends educational resources.
• Performs or delegates in-home supervision of team members.
• Attends regular team meetings.
• Monitors the productivity of team members on a regular basis.

5. Identifies staffing needs and communicates this information. Participates with human resource management to achieve quality service delivery and positive employee relations.

• Conducts timely home health aide performance evaluations consistent with Agency policy. Conducts in-home supervision of LPN’s and home health aide staff per Agency policy, regulatory requirements, and as needed.
• Assists with disciplinary procedures in a fair and consistent manner when indicated. Documentation is completed per policy and legal guidelines.
• Collaborates with supervisors to identify staffing needs and evaluate qualifications and competencies of current and new employees.

6. Promotes personal safety and a safe environment for clients and coworkers.

• Demonstrates knowledge of safety and infection control practices by compliance with policies and procedures.
• Recognizes and responds appropriately to potentially unsafe situations.
• Demonstrates safe and competent practice in the use of equipment.
• Assesses safety of environment and takes initiative to prevent accidents and promote safety.
• Participates in all mandatory education per established agency guidelines.

7. Performs job duties in accordance with Agency policies, procedures, and professional and community standards.

• Maintains confidentiality in all aspects of the job. Does not reveal information from client records to others, except as identified in Agency policy.
• Secures written confidential documents in a manner that prevents unauthorized release.
• Participates in the development, implementation, and evaluation of the Quality Improvement Program and activities.
• Provides care in accordance with state and federal regulations and accreditation standards.
• Follows established Agency guidelines for protection of confidentiality of all written and computer files.
• Protects personal password in accessing client and/or personnel files

8. Performs other job duties as assigned.

• Completes assigned tasks within established guidelines and time frames.

Physical/Environmental Demands

See ADA Requirements. I have read and understand the above job description of the RN Case Manager.