RN Case Manager- Home Health

Job Title

RN Case Manager
- Home Health

Full time

Day (United States of America)

1615 Franklin Rd - Roanoke CP01 Carilion Medical Center.

R156524 RN Case Manager
- Home Health (Open)

• Assesses, plans, implements, and evaluates patient care to achieve optimum patient outcomes for patients of all ages as appropriate to service area.
• Understands Hospice concept of care and the complex issues related to caring for the terminally ill. Provides competent, compassionate care in a variety of settings.
• Age specific admission and ongoing assessments are completed, documented and used to develop a plan of care.
• Collaborates with other members of the health care team/patient/family to develop, implement, and evaluate an age‑specific interdisciplinary plan of care. Revises plan according to changes in patient status.
• Administers and documents treatments and medications for patients utilizing automated computer systems, including electronic medical records.
• Ensures patient care orders are current, accurate, implemented, and evaluated for effectiveness per provider order.
• Identifies patient/family (caregiver) educational needs, incorporates education into the plan of care, and documents.
• Contributes to Carilion Clinic’s performance improvement activities.
• Advocates for patient, protects patient’s rights, and provides psychological, social, and cultural support.
• Plans, coordinates, and provides clinical care in a way that promotes positive patient outcomes, promotes safety during vulnerable periods of transition, and upholds a culture of patient‑centered care.
• Exhibits clinical expertise in rapidly changing circumstances.
• Plans strategies to prevent avoidable re‑hospitalizations, reduce length of stay, turnaround time, resource consumption, and improve patient outcomes.
• Seeks direction from supervisor as needed in order to affect the best possible outcome for patients served.
• Manages resources, establishes priorities, and modifies environment to meet patient care needs.
• Completes manager/director predetermined projects within specified time frame and according to pre‑established guidelines.
• Facilitates resolutions for patient and work situations.
• May provide orientation to new employees.
• May supervise LPN as required per regulatory guidelines. LPN supervision will require additional caseload numbers for RN/LPN team.
• Keeps case management worksheet up to date.
• Manages case conferences on assigned patients.
• May supervise Home Health Aides and evaluations.
• Ensures visit frequencies reflect orders and are appropriate with evidence‑based practice.
• Collaborates with centralized scheduling to ensure appropriate adjustments to visit frequencies are made as needed.
• Collaborates with billing to ensure pre‑authorization is appropriately secured and patient financial obligations are communicated.
• Performs skilled visits including OASIS visits as needed. "Case Manager" preferably performs recertification visit. Creates new plan of care 485/486.
• Coordinates appropriate provision of BIPA and ABN forms or any others as directed by CMS or agency policy.
• Utilizes Mifi device to access information promoting quality of care and continuity. Mifi is also to be utilized to frequently transfer device to promote hand‑off of communication.

Education: Graduate of accredited Registered Nurse Program.

Experience: None.

Licensure/Certification s/Registration: Currently licensed as Registered Nurse in the state of Virginia or approved compact state. Must have valid driver’s license, automobile insurance, and personal vehicle for making home visits.

Other

Minimum Qualifications:

Keyboarding skills required for automated computer systems, including electronic medical records. Demonstrates knowledge of the principles of life span growth and development and assesses data reflective of the patient’s status. Interprets the appropriate information needed to identify each patient’s requirements relative to his or her age specific needs and provides care according to departmental policies and procedures. Work involves application of advanced knowledge and skills of patient care.

Strong critical thinking…