RN Case Manager

Job Summary

To provide prescribed nursing care services to the ill, injured, convalescent and disabled persons in the home care setting by following a Plan of Care (POC) according to the patient’s needs. This includes comprehensive health and psychological evaluation, monitoring of the condition, health promotion and prevention coordination of services, teaching and training activities and direct nursing care.

Must use the ability to transfer scientific knowledge from social, biological and physical sciences in the application of the nursing process.

• Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet.
• Evaluate the patient, family members, and home environment to determine required health teaching and available assistance from family caregivers.
• Perform accurate assessments, develop and implement a written Plan of Care, and document nursing interventions, patient education, and adapt actions as patient needs change.
• Demonstrate knowledge and competency in performing baseline nursing skills as outlined in agency policy and clinical policy, maintaining clinical competencies according to home care standards and compliance with the state practice act.
• Provide head‑to‑toe nursing assessment, certify patient home‑bound status following Medicare guidelines, and indicate level of supervision required.
• Document patient status accurately and concisely, addressing needs, problems, interventions, patient response, safety measures, and education, with clinical notes submitted no later than 48 hours after visit.
• Evaluate the ongoing effectiveness of nursing services to the patient and family.
• Perform admission, transfer, re‑certification, resumption of care, and discharge skilled nurse visits.
• Assist the agency by performing orders such as assessments, wound care, lab draws, IV access, etc.
• Administer all medications and treatments in accordance with agency policy, accepted standards of care, and home care guidelines.
• Communicate effectively with other nurses, patients, families, and physicians, documenting status, needs, interventions, responses, and safety measures.
• Discuss with the supervisor the need for involvement of other health team members (Home Health Aide, Physical Therapist, Speech Therapist, Occupational Therapist, Medical Social Worker, etc.).
• Demonstrate organization and leadership by effective use of time and personnel, supervising and teaching, establishing priorities, and delegating responsibilities when supervising LPN and HHA.
• Maintain a cooperative attitude, promote teamwork and harmony, and assist other staff and patients; participate in case conferences and team meetings.
• Make visits as scheduled, participate in on‑call rotation, work independently without on‑site supervision, and submit accurate timesheets and daily visit tallies.

• Conform to all applicable Agency policies and procedures.
• Perform related duties as assigned or requested.
• Continuously strive to improve nursing care by attending in‑service education, formal education, workshops, conferences, goal setting, and professional organization participation.
• Assume accountability for reporting incidents and complaints according to Agency policy.
• Possess adequate knowledge of Medicare and insurance standards to ensure reimbursement for all services rendered.

• Pass a criminal background check.
• Pass a drug test.
• Fill out and submit a timely timesheet.
• Respect and maintain company technology in your care.

• Advanced written and verbal communication skills.
• Organizational and time‑management skills.
• Ability to supervise in accordance with agency policies and applicable laws.
• Ability to respond to inquiries, complaints, regulatory agencies, or business community members.
• Friendly and cooperative attitude with patients, family, and staff.
• Contribute to quality of care through constructive communication with nursing managers and staff.
• Use critical thinking to resolve problems.

Must use a computer to check email, complete training, and manage the…