Registered Nurse Case Manager

Registered Nurse (RN) / Case Manager Support

A Registered Nurse (RN) / Case Manager Support administers and/or oversees the skilled nursing care of patients in their place of residence in accordance with physician orders and the plan of care per state Practice Act. This role blends hands-on nursing with case management responsibilities on an intermittent basis, ensuring patients receive comprehensive, individualized, and high-quality home health services in alignment with the physician orders, regulatory requirements, and organizational policies.

• 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 and/or, 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 those 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 summaries.
• 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 with physician's orders to Physical Therapist, Speech Language Pathologist, Occupational Therapist and Medical Social Worker for those patients requiring their specialized skills.
• Understands and adheres to the 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) quarterly and as assigned. 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 as applicable.
• 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 judgment.
• Ability to successfully meet all background and clearance requirements including maintenance of up-to-date CPR…