Case Manager

The Case Manager is a qualified registered nurse empowered to provide and oversee the care of assigned patients and associated staff in accordance with physician orders and the plan of care per state Practice Act.

• Develop, deliver, implement, revise, and evaluate individualized patient‑centered care plans under physician supervision.
• Provide case management to an assigned group of patients and ancillary staff.
• Submit required data collection sets (OASIS, PAR, etc.) and other documentation to state, federal, and insurance payers within required time frames.
• Make initial evaluation visits and regularly reevaluate patient nursing needs per state and payer requirements.
• Advocate for patient welfare and coordinate care between patients, families, authorized representatives, the agency, and other healthcare providers or facilities.
• Administer services requiring substantial specialized nursing skill according to competency level.
• Demonstrate problem‑solving and positive interpersonal communication skills.
• Identify care preferences of patients and verify that interventions meet their needs and goals of treatment.
• Initiate appropriate preventive and rehabilitative nursing procedures.
• Prepare clinical and progress notes for each patient visit and summary.
• Attend case conferences as assigned.
• Inform physician and other personnel of changes in patient condition and needs.
• Counsel patient and family in meeting nursing and related needs.
• Educate on proper home health strategies and procedures utilizing community resources.
• Observe and report patient symptoms, reactions to treatments, drugs, and changes in physical or emotional condition.
• Perform medication reconciliation.
• Participate in in‑service programs, supervising and teaching nursing personnel as assigned.
• Administer medication per agency policy and physician orders.
• Provide written instructions for aides or other ancillary disciplines caring for the patient.
• Process orders and notify physician of patient needs and changes in condition.
• Refer cases to Physical Therapist, Speech Language Pathologist, Occupational Therapist, and Medical Social Worker when specialized skills are required.
• Adhere to Policy/Procedure, Best Practices, Infection Control Plan, EMS Plan, and Compliance Plan.
• Participate in clinical record/utilization review of medical records and quality assurance and performance improvement (QAPI).
• Report and record all applicable infections, occurrences, and complaints.
• Submit documentation within 24 hours or per state requirements.
• Maintain confidentiality of patient, employee, and agency matters.
• Perform on‑call duty nights, weekends, and holidays; act as after‑hours supervising nurse, making assessments and triage decisions as directed.
• Immediately report to Nursing Supervisor any patient incidents, variances, or complaints.
• Demonstrate competent performance of technical skills according to established procedures.
• Maintain acceptable attendance status per agency policy.
• Report all incomplete work assignments to Nursing Supervisor.
• Manage time through daily documentation and infrequent overtime for routine assignments.
• Ensure written instructions are given to patient/caregiver regarding visit schedule, medication profile, treatments, and agency contact information.
• Perform all other duties as assigned.

• Average computer skills with competency in media communications.
• Physical ability to perform described duties.
• Organize work through time management and supervise ancillary disciplines as state requires.
• Secure transportation and travel as required.
• Apply professional training to critically analyze patient needs, follow physician orders, and produce accurate records.
• Exercise initiative and independent judgment.
• Meet…