RN Case Manager

Case Manager Responsibilities

• Develops, delivers/implements, revises, and evaluates individualized patient‑centered care plans under the supervision of a physician.
• Provides case management to an assigned group of patients and ancillary staff.
• Understands and submits required data collection sets (OASIS, PAR, etc.) and other documentation as requested by the state, federal government, and insurance payers within required time frames.
• Makes the initial evaluation visit and regularly reevaluates the patient’s nursing needs per state and payer requirements.
• Acts as an advocate for patient welfare, coordinating care between patients, their families/caregivers, authorized representatives, the agency, and other healthcare providers/facilities.
• Furnishes services requiring substantial specialized nursing skill according to competency level.
• Demonstrates problem‑solving abilities and positive interpersonal communication skills.
• Identifies care preferences of patients and verifies that interventions meet the patient’s needs and treatment goals.
• Initiates appropriate preventive and rehabilitative nursing procedures.
• Prepares clinical and progress notes for each patient visit and summarizes findings.
• Attends case conferences as assigned.
• Informs physician and other personnel of changes in the patient’s condition and needs.
• Counsels the patient and family/significant others in meeting nursing and related needs.
• Educates on proper home health strategies and procedures using community resources as applicable.
• Observes and reports patient symptoms, reactions to treatments, drugs, and changes in the patient’s physical or emotional condition; responsible for medication reconciliation.
• Participates in in‑service programs, supervising and teaching other nursing personnel as assigned.
• Administers medication per agency policy and physician orders.
• Provides written instructions for aides or other ancillary disciplines caring for the patient.
• Processes orders and notifies physician of patient needs and changes in condition.
• Refers cases with physician orders to Physical Therapist, Speech–Language Pathologist, Occupational Therapist, and Medical Social Worker when specialized skills are required.
• Understanding and adhering to Policy/Procedure, Best Practices, Infection Control Plan, EMS Plan, and the Compliance Plan.
• Participates in clinical record/utilization review of medical records and quality assurance and performance improvement (QAPI) quarterly and as assigned.
• Reports and records all applicable infections, occurrences, and complaints.
• Submits documentation within 24 hours or as per state requirements.
• Maintains confidentiality of patient, employee, and agency matters.
• Provides on‑call duty nights, weekends, and holidays as assigned; acts as the after‑hours supervising nurse when on‑call.
• Immediately reports to Nursing Supervisor any patient incidents, variances, or complaints.
• Demonstrates competent performance of technical skills according to established procedures.
• Maintains acceptable attendance status per Agency policy.
• Reports all incomplete work assignments to Nursing Supervisor.
• Demonstrates effective time management skills through daily documentation and infrequent overtime for routine assignments.
• Ensures that visit schedule, medication profile, treatments administered by agency staff, and other pertinent instructions are given in writing to the patient, caregiver, or representative.
• Performs all other duties as assigned.

• Average computer skills with competency in media communications.
• Physical ability to perform the described duties.
• Ability to organize work procedures through time management, assume responsibility, and effectively supervise ancillary disciplines per state requirements.
• Capability to secure transportation and travel as required.
• Application of professional training to critically think through patient needs, follow physician’s orders, and produce accurate records of nursing activity within agency guidelines.
• Acceptance of the agency’s philosophy and goals.
• Ability to exercise initiative and independent judgment.
• Compliance with health requirements for clearances and current CPR.
• Maint…