Home Health Registered Nurse Case Manager

Job Details

Title: RN Case Manager

Division: Senior Services

Status: Non‑Exempt

Reports to: Director of Clinical Management

Revision date: March 2025

Supervises: N/A

According to prescribed policies and procedures of the organization including all applicable federal, state and local regulations and under the general supervision of the Director of Clinical Management, the RN Case Manager is responsible for providing nursing care services and case management to client, caregiver, and client representative by implementing nursing interventions as ordered by the physician and set forth by the plan of care.

Assists in overseeing direct care staff members to deliver quality care and coordinates delivery of care services.

This position does not have a set weekly schedule. Duties and schedule are as assigned, consistent with part‑time or contingent.

• Assuring the development, implementation, and updates of individualized plans of care, including communication with all physicians involved and integration of orders for medications. Includes the client, caregiver, and client representative in the planning process.
• Develops individualized plans of care with the involvement of the client, caregiver, and client representative and provides education, mentoring, and support throughout the plan. Notifies the client, caregiver, and client representative of necessary plan changes.
• Uses health assessment data to determine problems, goals and interventions. Communicates with community health providers and facility staff to coordinate the care plan. Works with interdisciplinary team and physician/physician extender to establish, monitor and document ongoing home health eligibility.
• Completes an initial assessment of client, caregiver, and client representative to determine home care needs. Performs a complete physical assessment and obtains history of current and previous illnesses; initiates appropriate preventive and rehabilitative nursing procedures; may administer medications and treatments as prescribed by the physician/physician extender.
• Communicates with the physician/physician extender regarding the client’s needs and reports any changes in the client’s condition; obtains and receives physician’s/physician extender’s orders as required.
• Prepares clinical notes and updates the primary physician/physician extender when necessary.
• Provides direct client care as defined in the State Nurse Practice Act.
• Educates and mentors the client, caregiver, and client representative in providing care related needs per plan of care. Provides support and education on end‑of‑life issues and care to clients and caregivers.
• Regularly re‑evaluates client nursing needs. Initiates the plan of care and makes necessary revisions as client status and needs change.
• Coordinates discharge planning in conjunction with interdisciplinary members when appropriate.
• Attends and participates in scheduled interdisciplinary team meetings to coordinate care plans, follow‑up on changes, problem‑solve, and ensure client’s care and treatment are properly communicated, documented and aligned with the physician’s/physician extender’s orders.
• Responsible for instruction, evaluation, plan development, and supervision of the LPN/LVN, HH/Hospice aides per conditions of participation and policy, including competency evaluation.

• Demonstrates and maintains a positive, professional manner, manages time efficiently and effectively, provides leadership as a role model, promotes a team approach, collaborates and participates in policy creation and appropriate problem‑solving methods.
• Adheres to all policies, procedures, terms and conditions set forth in the National Church Residences’ Employee Information Guide (EIG), the Code of Conduct, and any facility handbook, including but not limited to corporate compliance, drug‑free workplace, safe work practices, and all federal, state, local regulations and laws.
• Ensures all care is provided with respect and dignity for residents/clients, families and staff; reports all complaints, allegations of abuse, misappropriation of funds/resident property, and any other compliance issues to the appropriate…