RN Case Manager Home Health

Job Summary

The RN Case Manager is responsible for providing and supervising primary care to approximately 25-35 patients in their home setting. The role involves delivering age‑appropriate interventions that meet physical, emotional, developmental, psychosocial and educational needs, coordinating all disciplines throughout the episode of care, and ensuring the patient’s plan of care is appropriately developed, implemented, and goals are met.

Direct Patient Care

• Assesses, coordinates with other disciplines and manages patient’s total needs following physician’s orders and the nursing process.
• Develops patient’s plan of care in coordination with other disciplines.
• Manages patient from admission through recerts to discharge, appropriately scheduling visits per physician’s order and adjusting frequency as needed.
• Performs routine and complex nursing procedures to meet the patient’s needs.

Coordination of Services for Episode of Care

• Revises the plan of care based on patient need within physician orders, coordinating with other disciplines to achieve positive outcomes prior to discharge.
• Supervises LPNs and Home Health Aides throughout the continuum of care.
• Develops and supervises the care plan provided to Home Health Aides.
• Reviews plan of care with Manager Home Health and other team members and support services.
• Maintains communication with physician reporting any changes that may affect patient recovery.

Patient / Caregiver Education

• Provides education to develop and encourage self‑care to achieve positive outcomes.
• Utilizes verbal and written tools to facilitate learning and promotion of independence during recovery.
• Reports concerns to authorities or agency leadership on any issues that affect patient or staff safety.

Staff Education and Professional Development

• Participates in orientation and education of new employees as appropriate.
• Attends continuing education and in‑services as directed and needed.
• Remains current in clinical knowledge for the care of the home health patient.
• Receives training, supervision or direction from leadership as needed.

Communication

• Communicates patient status changes and lab results to the physician as appropriate.
• Participates in care team conferences.
• Checks voicemail box and staff messaging at least once daily.

Regulatory Guidelines

• Demonstrates knowledge of CMS/State and Joint Commission regulatory guidelines.
• Accurately completes required OASIS and visit documentation in the patient's EMR.
• Completes all documentation within established time frames.

Supports and Participates in Performance Improvement Activities

• Participates in department performance improvement activities (e.g., chart review, committees).
• Participates in system‑wide committees as requested.
• Identifies methods for improving department performance and care.
• Assists in implementing performance improvement opportunities.

Other Responsibilities

• Meets established productivity standards.
• Participates in weekend and call rotation as required.
• Performs other duties as assigned by Home Health Leadership.

Graduate of an approved school of professional nursing.

• Registered Nurse (Single State) – 1.00
• RN – Multi‑state Compact – 1.00
• Basic Life Support – 2.00
• BLS – Instructor – 2.00
• BLS – Provisional – 2.00

• Minimum 1 year of Medical/Surgical Nursing, Home Health, and ICU experience.
• Must possess extremely strong critical care nursing skills.

• Strong critical care assessment and clinical skills.
• Positive leadership, problem‑solving, strong organizational and time‑management skills.
• Strong communication (written and verbal) skills.
• Ability to write and follow directions to patient homes.
• Proficient with Windows‑based computer, home health patient software, email, internet, computer‑based learning modules.
• Good understanding of home health operations, reimbursement, law and regulatory processes.
• OASIS knowledge preferred.

Join us and discover the support to do more meaningful work and enjoy a more rewarding life with the most integrated health system in Georgia. Start a future that gives you more.