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Rochester Regional Health

Integrated system of hospitals, clinics, labs

Registered Nurse Case Manager - Palliative Case Manager, Home Care

Nursing & Frontline Patient CareConfirmed live in the last 24 hours
Full-timeRochester, NY, USA$80.3k - $107k

About the Job

Requirements

  • A Diploma or Associate’s Degree in Nursing is required.
  • A Registered Nurse license in New York State is required.
  • Frequent driving, mobile clinical care across settings, and the physical ability to repeatedly enter and exit vehicles and occasionally lift and carry equipment weighing up to 100 lbs. or more are required.
  • The role requires fine and gross motor control, firm grasping, heightened visual and auditory awareness, rapid decision-making, and the ability to independently manage patient care in field or home settings.
  • The role requires flexibility for extended or on-call schedules.

Responsibilities

  • Identify and prioritize health problems based on assessment.
  • Develop or implement an interdisciplinary Plan of Care based on identified needs, with input from the patient and caregivers as applicable, in collaboration with the attending physician and other care team members.
  • Manage and coordinate patient care, including clinically complex cases, to ensure efficient and effective delivery of appropriate services and community supports.
  • Complete comprehensive assessments and documentation accurately, including payer-required assessments such as OASIS and HIS when applicable.
  • Plan, organize, and prioritize care needs for an assigned caseload to ensure patient needs are met and services are delivered according to the Plan of Care.
  • Communicate changes in patient status or service needs to the appropriate care team member and ensure timely action.
  • Facilitate patient discharge plan development and implementation as indicated.
  • Document patient care and coordination activities according to agency standards.
  • Assess the need for additional services, including aides, therapies, social work, or community services, and obtain orders and arrange care as indicated.
  • Supervise and evaluate care provided by Licensed Practical Nurses and/or home health aides in performing patient-care duties.
  • Work collaboratively with care team members by communicating changes in patient status or service needs and ensuring timely action.
  • Identify patient and family risk factors and establish goals and interventions to reduce or remove risk from the Plan of Care so patients can remain in the least restrictive care setting.
  • Coordinate or participate in interdisciplinary team meetings and patient care conferences.
  • Provide visits outside the primary team assignment or geographic area when needed to meet patient needs.
  • Practice according to agency and community standards.
  • Participate in utilization review and/or continuous quality improvement activities as requested.
  • Attend required staff meetings, in-services, and supervisory conferences.
  • Participate in on-call, weekend, and holiday schedules as assigned.

Desired Qualifications

  • One year of nursing experience is preferred.
  • Prior home health, clinical, and direct patient care experience is preferred.

About the Company

Rochester Regional Health

Integrated system of hospitals, clinics, labs

Rochester Regional Health is a regional health system that provides integrated medical care across Western New York and beyond, with 500+ locations, including 8 hospitals, clinics, rehabilitation centers, senior services, behavioral health, and clinical trials. Patients access care through its network of hospitals, clinics, rehab centers and labs, with care coordinated across locations and teams handling prevention, diagnosis, treatment, rehabilitation and ongoing support. The organization stands apart by offering a wide range of services under one umbrella, enabling continuous, coordinated care within a single system, with a focus on neighbor-driven, community-based, real-life care. Its goal is to help the community stay healthy and live fulfilling lives by delivering accessible, comprehensive, patient-centered health care for people at every age and stage.

Company size
10,001+
Company stage
Grant
Total funding
$600K
Headquarters
Rochester, NY
Founded
Not listed

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