Registered Nurse Case Manager

Responsibilities

• Develops, delivers/implements, revises, and evaluates individualized patient-centered care plans under the supervision of a physician.
• Provides case management to an assigned group of patients and ancillary staff.
• Understands and submits required data collection sets (OASIS, PAR, etc.) and other documentation as requested by the state, federal government, and insurance payers within required time frames.
• Makes the initial evaluation visit and regularly reevaluates the patient’s nursing needs per state and payor requirements.
• Acts as an advocate for patient welfare and coordinates care between patients, their families/caregivers and/or their authorized representative, the agency and other healthcare providers/facilities/ outside agencies.
• Furnishes services requiring substantial specialized nursing skill according to competency level.
• Identifies care preferences of patients and verifies that interventions meet the patient’s needs and their goals of treatment.
• Initiates appropriate preventive and rehabilitative nursing procedures.
• Prepares clinical and progress notes for each patient visit and summary.
• Attends case conferences as assigned.
• Informs physician and other personnel of changes in the patient’s condition and needs.
• Counsels the patient and family/significant others in meeting nursing and related needs.
• Educates on the proper home health strategies and procedures utilizing community resources as applicable.
• Observes and reports patient symptoms, reaction to treatments, drugs and changes in the patient’s physical or emotional condition, responsible for medication reconciliation.
• Participates in in-service programs, supervising and teaching other nursing personnel as assigned.
• Administers medication per agency policy and physician orders.
• Provides written instructions for aides or other ancillary disciplines caring for the patient.
• Processes orders and notifies physician of patient needs and changes in condition.
• Refers cases requiring specialized skills to the appropriate therapists and medical social worker.
• Understands and adheres to policy/procedure, best practices, infection control plan, EMS plan and compliance plan.
• Participates in clinical record/utilization review of medical records and quality assurance and performance improvement (QAPI).
• Reports/records all applicable infections, occurrences, and complaints.
• Submits documentation within 24 hours or per state requirements.
• Maintains confidentiality of patient, employee, and agency matters.
• Takes on-call duty nights, weekends, and holidays, as assigned.
• When functioning as the on-call RN acts as the after-hours supervising nurse and makes nursing assessment and triage decisions under the guidance of the overall Clinical Supervisor.
• Immediately reports to Nursing Supervisor any patient incidents/variances or complaints.
• Maintains acceptable attendance status, per Agency policy.
• Reports all incomplete work assignments to Nursing Supervisor.
• Ensures that the following information/instruction is given in writing to the patient/caregiver/representative: visit schedule with frequency of visits; complete medication profile; any treatments to be administered by agency staff (POC); any other pertinent instruction related to the patient’s care needs; name and contact information of the agency’s Clinical Manager.
• Performs all other duties as assigned.

• Excellent problem-solving abilities and positive interpersonal communication skills.
• Competent performance of technical skills according to established procedures.
• Effective time management skills through daily documentation and infrequent overtime for routine assignments.
• Adequate computer skills with competency in media communications.
• Ability to assume responsibility and effectively supervise ancillary disciplines per state requirements.
• Ability to secure transportation and travel as required.
• Ability to apply professional training to critically think through patient needs, follow physician’s orders and produce accurate records of nursing activity within agency guidelines.
• Acceptance of philosophy and goals of this Agency.
• Ability to exercise initiative and independent…