Home Health RN Case Manager

The Registered Nurse (RN) Case Manager provides skilled nursing care and case management to patients in their homes. This role involves assessing patient needs, developing and implementing individualized care plans, coordinating care with the interdisciplinary team, and ensuring compliance with state and federal regulations. The RN Case Manager serves as a liaison between patients, families, physicians, and other healthcare providers to ensure high-quality and compassionate care.

Essential Functions:

Conduct comprehensive initial and ongoing assessments to identify and evaluate the physical, psychosocial, environmental, and health status needs of patients.

Develop, implement, coordinate, and revise individualized plans of care in collaboration with patients, caregivers, physicians, and the interdisciplinary team to ensure quality, continuity, and appropriateness of care.

Provide skilled nursing services, treatments, and interventions requiring specialized nursing knowledge in accordance with physician orders, agency policies, and the established plan of care.

Regularly evaluate patient progress, reassess nursing needs, monitor outcomes, and promptly communicate significant changes in condition to physicians and other members of the care team.

Administer medications, treatments, and therapeutic procedures as prescribed and monitor patient response.

Coordinate patient care and transitions across healthcare settings, including hospitals, rehabilitation facilities, physicians, community resources, and home environments.

Integrate and manage physician orders from all applicable healthcare providers, ensuring timely implementation and physician approval as required.

Educate and counsel patients, families, and caregivers regarding disease management, medications, treatments, safety practices, self-care techniques, and discharge planning.

Initiate preventive, restorative, and rehabilitative nursing measures and make referrals to other disciplines or community resources as appropriate.

Advocate for patients to ensure access to appropriate healthcare services, resources, and support systems.

Supervise assigned LVNs/LPNs, home health aides, and other paraprofessional staff in accordance with regulatory and agency requirements, including competency evaluations when qualified.

Maintain accurate, complete, and timely clinical documentation, assessments, care plans, progress notes, and case management records.

Monitor assigned caseloads to ensure compliance with payer requirements, physician orders, agency policies, accreditation standards, and applicable federal, state, and local regulations.

Collaborate effectively with patients, families, physicians, caregivers, and interdisciplinary team members to promote optimal patient outcomes.

Adhere to accepted infection prevention and control practices and maintain a safe, clean, and therapeutic environment for patients and staff.

Participate in on-call rotations and provide after-hours nursing support as assigned.

Support the agency's mission, values, and goals by maintaining a professional, positive image and providing exceptional patient-centered care.

Participate in required education, in-service training, competency validation, professional development activities, and Quality Assurance and Performance Improvement (QAPI) initiatives.

Meet established productivity and performance standards.

Maintain compliance with professional nursing standards, ethical principles, agency policies, and all applicable legal and regulatory requirements.

Perform other duties as assigned.

Education:

Graduate of an accredited nursing program (associate or bachelor’s degree in nursing).Licensure:

Current Registered Nurse (RN) license in the State of Texas.

Current driver’s license.

Experience:

Mini…