RN Case Manager- Home Health

Position Title

RN Case Manager – Home Health

100 Spotswood Dr - Lexington, VA

Full-time, Day shift (United States)

• Assesses, plans, implements, and evaluates patient care to achieve optimal outcomes for patients of all ages within the service area.
• Understands hospice concepts of care and complex issues related to caring for the terminally ill. Provides competent, compassionate care in multiple settings.
• Completes age‑specific admission and ongoing assessments, documents findings, and uses data to develop a plan of care.
• Collaborates with healthcare team, patients, and families to develop, implement, and evaluate an interdisciplinary, age‑specific plan of care, revising it as patient status changes.
• Administers and documents treatments and medications via automated computer systems, including electronic medical records.
• Ensures patient care orders are current, accurate, and evaluated for effectiveness per provider order.
• Identifies patient/family educational needs, incorporates education into the plan of care, and documents it.
• Contributes to Carilion Clinic’s performance improvement activities.
• Advocates for patients, protects patient rights, and provides psychological, social, and cultural support.
• Plans, coordinates, and provides clinical care that promotes positive outcomes, safety during transitional periods, and a culture of patient‑centered care.
• Exhibits clinical expertise in rapidly changing circumstances.
• Develops strategies to prevent avoidable rehospitalizations, reduce length of stay, turnaround time, and resource consumption while improving outcomes.
• Seeks direction from supervisors as needed to achieve best possible outcomes for patients.
• Manages resources, establishes priorities, and modifies the environment to meet patient care needs.
• Completes manager/director‑predetermined projects within specified time frames and according to guidelines.
• Facilitates resolution of patient and workplace matters.
• Provides orientation to new employees when required.
• May supervise LPNs in accordance with regulatory guidelines, ensuring additional caseloads per RN/LPN team.
• Maintains case‑management worksheets; manages case conferences; supervises Home Health Aides; evaluates visit frequencies and ensures they align with evidence‑based practice.
• Coordinates with centralized scheduling and billing to adjust visit frequencies and confirm pre‑authorization and patient financial responsibilities.
• Performs skilled visits including OASIS visits; “Case Manager” should conduct recertification visits; creates new plans of care using forms 485/486.
• Coordinates appropriate provision of BIPA and ABN forms per CMS or agency policy.
• Utilizes MIFI device to access information and promote continuity of care, including frequent transfers to facilitate communication.

• Education:
  
  Graduate of an accredited Registered Nurse Program.
• Experience:
  
  None required.
• Licensure:
  Currently licensed as a Registered Nurse in the state of Virginia or another approved compact state.
• Driver’s License and personal vehicle for home visits.
• Keyboarding skills required for automated computer systems, including electronic medical records.
• Knowledge of life‑span growth and development principles; ability to assess data reflecting patient status; interpret regulations related to CHCS and Carilion Clinic.
• Strong critical thinking and prioritization skills in a fast‑paced patient care environment.

• Comprehensive Medical, Dental, & Vision Benefits
• Employer‑Funded Pension Plan (vested after five years) and voluntary 403(b) option
• Paid Time Off accrued from day one
• Onsite fitness studios and discounts to Carilion Wellness centers
• Health and wellness app access (Virgin Pulse)
• Childcare discounts
• Continued education and training opportunities
• Sign‑On Bonus eligibility, company equipment, and mileage reimbursement

Carilion Clinic is an Equal Opportunity

Employer:

We provide equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, national origin, age (40 or older), disability, genetic information, or veteran status. Carilion is a Drug‑Free Workplace. For more information or for individuals with disabilities needing assistance with our online application process, contact Carilion HR Service Center at 800‑599‑2537, 8:00 a.m. to 4:30 p.m., Monday through Friday.

For more information on E‑Verify, visit https://(Use the "Apply for this Job" box below)..