RN Case Manager

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.

• 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…