Registered Nurse Case Manager

Job Summary

To provide prescribed nursing care services to the ill, injured, convalescent and disabled persons in the home care setting by following a Plan of Care (POC) according to the patient's needs. This includes comprehensive health and psychological evaluation, monitoring of the condition, health promotion and prevention, coordination of services, teaching and training activities, and direct nursing care.

Must use the ability to transfer scientific knowledge from social, biological and physical sciences in the application of the nursing process.

• Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet.
• Evaluate the patient, family members and home to determine necessary health teaching.
• Evaluate the patient's environment to determine whether assistance will be available from family members caring for the patient.
• Perform accurate assessments, develop and implement a written Plan of Care with the patient following physician's orders and according to agency guideline; perform and document nursing interventions including patient education and adapt actions as patient needs change.
• Demonstrate knowledge and competency in performing baseline nursing skills as outlined in agency policy and clinical policy; maintain clinical competencies according to hospice care standards and comply with state practice act.
• Provide head‑to‑toe nursing assessment and create a summary of the work performed; certify patient's homebound status by following Medicare guideline and indicate the level of supervision required thereafter.
• Document patient status in an accurate and concise manner as required by agency policy; address patients' needs and problems, nursing interventions, patient response, safety interventions and education. Submit clinical notes no later than 48 hours after the visit.
• Evaluate the effectiveness of nursing service to the patient and the family on an ongoing basis.
• Perform admission, transfer, re‑certification, resumption of care and discharge skilled nurse visits for the home care patient.
• Assist the agency by performing orders such as assessments, wound care, lab draws, IV's, etc.
• Administer all medications and treatments according to agency policy, accepted standards of care and home care guidelines.
• Communicate effectively with other nurses, patients, families and physicians; document patient status, patient needs/problems, nursing interventions, patient response, safety interventions and education/training.
• Discuss with the appropriate supervisor the need for the involvement of other members of the hospice team such as the Hospice Aide, the Physical Therapist, the Speech Therapist, the Occupational Therapist, the Medical Social Worker, etc.
• Demonstrate organization and leadership abilities by effective use of time and personnel through supervision and teaching; establish priorities and delegate responsibilities appropriately when supervising the LPN and HHA.
• Maintain a committed and cooperative attitude with staffing, promote teamwork and harmony by readily assisting other staff and patients, and participate in case conferences/team meetings.
• Makes visits as scheduled and participates in on‑call rotation as required. Work independently without on‑site supervision and submit a tally of patient care visits made each day along with an accurate timesheet.

• Conforms to all applicable Agency policies and procedures.
• Performs related duties as assigned or requested.
• Continually strive to improve nursing care by attending in‑service education, formal education, workshops, conferences, setting goals, active participation in professional and related organizations, and individual research.
• Assumes accountability for reporting incidents and complaints according to Agency policy.
• Possess adequate knowledge of Medicare and insurance standards to ensure reimbursement for all services rendered.

• Must pass a criminal background check.
• Must pass a drug test.
• Must have the ability to fill out and turn in a timesheet promptly.
• Must respect and take care of company technology placed…