Home Health RN Case Manager

Job Summary:The Home Health RN Case Manager is responsible to provide, coordinate, and monitor the health care services of agency clients. Ensures the safe delivery of quality care and regulatory requirements are met.

Job Relationships:

1. Reports to: Home Health Director (or designated Home Health Administrator in the absence of the Director) and Home Health Assistant Director.
2. Supervisory Responsibilities: Home Health Aides and Homemakers
3. Internal Relationships: Other RN Case Managers, Scheduler, Bethesda Social Service departments, Adult Day Director, Housing Managers and Coordinators, and Contracted Therapists.
4. External Contacts: Medical Director, Physicians, Pharmacists, Health Service personnel in surrounding area, Kandiyohi County Family Services Social Workers and Public Health Nurses, Nursing Home Social Workers, Hospital Discharge Planners, Insurance Company personnel, Clients and Family members, and other community providers.

Hours of Work: Full-time or Part-time; Monday through Friday; 8:00 a.m. to 4:30 p.m. Must be flexible for client needs. Rotating on-call duties when office is closed.

Dress Code: Street clothing or nursing uniform and identification badge.

Essential Requirements of Work: (Minimum qualifications necessary to function at full productivity.)

1. Education:
   1. Graduate of an accredited school of nursing.
   2. Current Minnesota registration as a Registered Nurse.
2. Experience:
   1. Strong proficiency in nursing skills.
   2. Home Health experience preferred, with a strong interest in geriatric nursing.
   3. Basic Computer skills.
3. Personal:
   1. Highly developed communication skills (oral and written).
   2. Proven time management skills.
   3. Understanding of basic quality principles.
   4. Adaptable to various work settings.
   5. Self-motivated.
   6. Attention to detail.
   7. Problem solving skills.
   8. Ability to direct and supervise.
   9. Ability to insure confidentiality.
   10. Ability to learn from mistakes.
   11. Provide a pleasant attitude and cheerful disposition towards staff, clients, and families.
   12. Own vehicle, current driver’s license and current automobile insurance.
4. Job Knowledge:
   1. Knowledge of nursing policies and procedures.
   2. Knowledge of infection control practices.
   3. Knowledge of State Federal regulatory requirements.
   4. Knowledge of the Nurse Practice Act.
   5. Ability to assess client’s condition with knowledge to provide necessary action.
   6. Supervisory knowledge and abilities.
   7. Philosophical understanding of quality of life and quality process management.
   8. Computer knowledge.

Physical Demands of the Job:

a. Repeated bending, squatting, stooping, sitting, climbing stars.

b. Occasional pushing/pulling movements of wheelchairs or clients weighing 100-250 pounds.

c. Frequent lifting over 25 pounds.

d. Frequent exposure to infection.

Principle Job Responsibilities:

Responsibility: Provide and monitor quality care.

Tasks:

1. Follow State and Federal regulations and agency policies and procedures.
2. Provide coordination of client care to ensure continuity and quality care.
3. Assess new admissions, transfers, and current clients to ensure proper services are in place.
4. Monitor all health changes of clients.
5. Communicate changes in client’s health to their doctor, family, and other appropriate personnel.
6. Assist with the scheduling of clients to Home Health Aides and Homemaker staff.
7. Review documentation of Home Health Aides and Homemakers.
8. Supervises Home Health Aides and Homemakers and complete supervisory visit documentation as required. Give feedback to the Home Health Aide and Homemaker as needed.
9. Follow infection control guidelines to prevent the spread of disease and infection.
10. Provide assistance to Home Health Aides and Homemakers in new or difficult situations.
11. Select appropriate client for Telemonitoring. Use and monitor results from Telemonitoring system.

Responsibility: Appropriately and safely perform procedures and treatments as ordered by Physician.

Tasks:

1. Procedures and treatments include but not limited to:
   1. Medication set-up and administration.
   2. Dressing changes.
   3. Catheterizations and catheter care.
   4. Colostomy care.
   5. Tube feedings.
   6. IV administration and site care.
   7. Vital Signs.
   8. Respiratory therapy including nebulizer treatments.
   9. Blood glucose monitoring.
   10. Blood draws.

Responsibility: Perform all documentation with accuracy and timeliness.

Tasks:

1. Complete necessary paperwork for admissions, transfers, deaths, and discharges.
2. Complete all required assessments.
3. Document each visit in CareFacts.
4. Complete Comprehensive and OASIS assessment in CareFacts when required.
5. Complete 485s and physician orders in CareFacts as required.
6. Complete Home Health Aide and Homemaker Care Plans prior to the initiation of those services.
7. Complete Communication Log after communications with client, family, health care providers, or staff.

Responsibility: Provide on-call nursing services on rotating basis when office is closed.

Tasks:

1. Carry on-call cell phone at all times.
2. Respond to calls received, assess the situation, and provide direction.
3. Document all phone calls.
4. Perform Skilled Nursing Visits as needed.

Responsibility: Marketing agency services

Tasks:

1. Present self in a professional manner.
2. Take referral as needed.
3. As opportunities arise, promote agency services to discharge planners, physicians, potential clients/families, and the general public.

Professional and Personal Growth:

1. Report for and leave the work area on a timely basis.
2. Participate in annual performance evaluation process.
3. Write yearly personal goals.
4. Participate in all required in-service programs at Bethesda.
5. Maintain a professional conduct and pleasant, friendly attitude towards staff, residents, and visitors.
6. Be willing to learn and change to meet needs that arise.