Registered Nurse Case Manager

Description

JOB SUMMARY: Perform duties as directed, by the Administrator or Clinical Manager. May be requested, by Clinical Manager, to fill in for the other supervisory staff, when necessary. Coordinate total patient care by conducting comprehensive health and psychosocial evaluation, monitoring the patient's condition, promoting sound preventive practices, coordinating services, and teaching and training activities. Evaluate the effectiveness of nursing service, to the patient and family, on an ongoing basis. Perform admission, transfer, re-certification, resumption of care, and discharge OASIS for the home care patient. Consult with the attending physician, concerning alterations of Patient Care Plans, checks with the appropriate supervisor, and makes changes, as appropriate. Coordinate patient services. Submit clinical notes, per agency policy, and progress notes and other clinical record forms, outlining the services rendered, as indicated. Participates in Clinical Record Review and QAPI. 

JOB SPECIFIC COMPETENCIES AS A REGISTERED NURSE/HIGH TECH REGISTERED NURSE

· Manage a case load of patients, and may supervise, other RN’s, LPN’s, HHA’s assigned to patients within the assigned case load.

· Participate in case conferences, discuss with the supervisor problems concerning the patients, and how they may best be handled.

· Discuss, with the appropriate supervisor, the need for the involvement of other members of the health team, such as the Home Health Aide, the Physical Therapist, the Speech Therapist, the Occupational Therapist, The Medical Social Worker, etc.

· Obtain orders for paraprofessional service and submit a referral to the appropriate personnel.

· Participate in the patient’s discharge planning process.

· Cooperate with other agencies providing nursing, or related, services to provide continuity of care and to implement a comprehensive care plan.

· Participate in staff development meeting.

· Continually strive to improve his/her nursing care skills by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations, and individual research and reading.

· Participate in the development, and periodic revision, of the physician's Plan of Treatment and processes change orders, as needed.

· Maintain an on-going knowledge of current drug therapy.

· Adhere to federal, state, and accreditation requirements, including Medicare and Medicaid regulations.

· May be requested to fill in for the other nurses.

· Conduct an initial, and ongoing, comprehensive assessment of the patient’s needs, including Outcome and Assessment Information Set (OASIS) assessments, at appropriate time points.

· Obtain a medical history from the patient, and/or a family member, particularly, as it relates to the present condition.

· Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet, etc.

· Evaluate the patient, family member(s), and home situation, to determine what health teaching will be required

· Evaluate the patient's environment to determine what assistance will be available, from family members, in caring for the patient.

· Evaluate the patient's condition, and home situation, to determine if the services of a Home Health Aide will be required and the frequency of this service.

· Explain nursing, and other agency, services to patients and families, as a part of planning for care.

· Develop, and implement, the nursing care plan.

· Nursing services, treatments, and preventative procedures, requiring substantial specialized skill, and ordered, by the physician.

· The initiation of preventative and rehabilitative nursing procedures, as appropriate, for the patient's care and safety.

· Observing signs, and symptoms, and reporting to the physician: reactions to treatments, including drugs, as well as changes in the patient's physical, or emotional, condition.

· Teaching, supervising, and counseling the patient, and caregivers, regarding the nursing care needs and other related problems of the patient, at home.

· Supervises the LPN/LVN, every 30 days

· Prepare the care plan for the Home Health Aide

· Supervise, and evaluate, the care given by the Home Health Aide, every 14 days and as needed per agency policy.

· Submit, to the appropriate department/individual, written evaluations of the Home Health Aides who are providing service to the patients in his/her geographical area

· Participate in periodic conferences, with the Home Health Aide supervisor, concerning the Aide's performance.

· Chart those services rendered to the patient, by the staff nurse, and changes that have been noted, in the patient's condition and/or family and home situation, make revisions in the nursing care plan, as needed, record supervisory visits conducted with the Home Health Aide, evaluate patient care and progress, and close charts of discharged patients.

· Provide guidance, and supervision, to the LPN and supervises the LPN, per agency policy.

· Participate in the educational experiences for student nurses.

· Participate in the planning, operation, and evaluation of the nursing service.

· Ensure that all OSHA/ACHC standards are in compliance.

· Work with Discharge Planners to identify, and plan, home infusion therapy referrals.

· Assess the patient on the initial visit, including an assessment of home safety, adequacy of refrigeration, storage, and cleanliness.

· Initiate the patient plan of care and make necessary ongoing revisions; provide service, in accordance with reimbursement, ethical, and legal guidelines.

· Administer venipuncture and handle insertion of intravenous needles and catheters.

· Prepare infusion solutions, with the addition of medications.

· Initiate, monitor, and terminate infusion solutions, and additives, and establish flow rates (if not done by the physician).

· Prepare clinical, and progress, reports and make referrals for other services, as appropriate.

· Inform the physician, and other appropriate personnel, of changes in the patient's needs.

· Train, both, the patient and caregiver and assess the ability of patient, or caregiver, to manage when staff is not present.

Requirements

EDUCATION, CREDENTIALS & EXPERIENCE REQUIREMENTS:

· Current Registered Nurse license

· Possesses the education, and experience, in the scope of services offered

· Must have at least one year hospital experience or two years of homecare experience, training, and experience.

· Must have a background check, including criminal history check, Office of Inspector General (OIG) Exclusions check and the National Sex Offenders Registry check.

· Active American Heart Association BLS certification within 30 days of hire.