Home Health Registered Nurse, RN, Case Manager

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. It also includes the following Home Care Nurse duties: assess, plan, implement, and evaluate the care needs of a designated group of patients or provide nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed.

The role requires a nursing license and may direct the work of other lower level professionals or manage processes and programs. The majority of the time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. This senior level role requires advanced knowledge of the job area typically obtained through advanced education and work experience.

Responsibilities include managing projects/processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, and resolving difficult and complex problems.

Utilizing the nursing process, the Home Health Registered Nurse will manage and deliver comprehensive home health services, including assessments, interventions, and supportive care to clients within their place of residence. Duties may also include telephone triage, problem solving, patient/caregiver advocacy and support, with an emphasis on avoiding hospitalization. As a key member of the health care team, this position must interact courteously and effectively with patients and their families, co‑workers from all agency departments, community resources, and patients’ physicians to facilitate safe and efficient patient care while maintaining the nurse’s own safety in the home and the community.

• Massachusetts RN Licensure and NH Licensure.
• Valid state issued Driver’s License.
• One (1) year of acute medical/surgical nursing experience.
• Basic Life Support Certification.

• Bachelor of Science in Nursing (BSN).
• Specialty nursing certifications.
• Three (3) years of acute nursing including medical/surgical, oncology, hospice, or home health.
• Experience with IV and complex wound care.

• Assesses patients' physical and psychosocial needs in a sensitive, caring manner following established Standards of Nursing Practice and Agency policies and procedures.
• Assesses patient/family learning needs, style, and limitations and makes adjustments for delivery of information.
• Recognizes and identifies patients/caregivers’ cultural beliefs regarding death and dying and is sensitive to those beliefs.
• Establishes realistic goals and develops a plan of treatment in cooperation with the patient, family and members of the health care team.
• Identifies abuse and/or neglect and follows the reporting mechanism per policy.
• Adapts to new and unusual situations without affecting work performance negatively, and utilizes security when and if needed for potential unsafe situations.
• Collaborates with patient/family and other health care providers and/or community resources for planning of care and discharge.
• Continuously assesses and evaluates patient and family progress and goal achievement, keeping Clinical Manager advised and justifying continuation and/or termination of services.
• Documents patient data, activities, and communications in patient record using the computer system in a timely, organized and concise manner to ensure compliance with legal, certification, third‑party payer guidelines and Agency policies.
• Completes physicians' orders, levels of care, and OASIS on all patients assigned, in accordance with patient care policies; reconciles medications with patient and physician consistently.
• Demonstrates and practices according to safety guidelines and procedures including general ergonomics, fire, and personal safety; utilizes proper body mechanics and patient material handling.
• Demonstrates an awareness of safety and security issues by responding appropriately to emergency situations and following established procedures and protocols utilizing stabilizing…