Registered Nurse Case Manager

Overview

Job Summary: To provide prescribed nursing care services to the ill, injured, convalescent and disabled persons in the home care setting by following a Plan of Care (POC) according to the patient's needs. This includes comprehensive health and psychological evaluation, monitoring of the condition, health promotion and prevention coordination of services, teaching and training activities and direct nursing care.

Must use the ability to transfer scientific knowledge from social, biological and physical sciences in the application of the nursing process.

Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet, etc. Evaluate the patient, family member(s) and home. Situation to determine what health teaching will be required. Evaluate the patient's environment to determine what health teaching will be required. Evaluate the patient's environment to determine what assistance will be available from family members caring of the patient.

Performs accurate assessments, develops and implements a written Plan of Care with the patients following physician's orders and according to agency guideline; performs and documents nursing interventions including patient education according to the plan of care and adapts these actions as patient needs change.

Must demonstrate knowledge and competency in performing baseline nursing skills as outlines in agency policy and clinical policy; maintains clinical competencies according to hospice care standards; complies with state practice act.

Must be able to provide head to toe nursing assessment and create a summary of the work performed. From a skilled nurse visit, certify patient's homebound status by following Medicare guideline. Indicate the level of supervision required from there on out.

Documents patient status in an accurate and concise manner as required by agency policy; addresses patients' needs and problems, nursing interventions and patient response, safety interventions and education and teaching. Submit clinical notes no later than 48 hours after the visit.

Evaluate the effectiveness of nursing service to the patient and the family on an ongoing basis.

Perform admission, transfer, re-certification, resumption of care and discharge skilled nurse visits for the home care patient.

Assist the agency by performing orders i.e. assessments, wound care, lab draws, IV's, etc.

Administers all medications, treatments according to agency policy, accepted standards of care and home care guidelines.

Communicates effectively with other nurses, patients, families, and physicians; documents patient status, patient needs/problems, nursing interventions/patient response, safety interventions and education/training.

Discuss with the appropriate supervisor the need for the involvement of other members of the hospice team such as the Hospice Aide, the Physical Therapist, the Speech therapist, the Occupational Therapist, the Medical Social Worker, etc.

Demonstrates organization and leadership abilities by effective use of time and personnel through the supervision and teaching; effectively established priorities and delegates responsibilities appropriately when supervising the LPN and HHA.

Maintains a committed and cooperative attitude with staffing, promoting teamwork and harmony by readily assisting other staff and patients; participates in case conferences/team meetings.

Makes visits as scheduled and participates in on-call rotation as required. Must be able to work independently without on-site supervision. In a timely manner submit a tally of patient care visits made each day along with an honest and accurate timesheet.

• Conforms to all applicable Agency policies and procedures.
• Performs related duties as assigned or requested.
• Continually strive to improve his/her nursing care by attending in-service education, through formal education, attendance at workshops, conferences, goal setting, active participation in professional and related organization and individual research.
• Assumes accountability for reporting incidents and complaint according to Agency policy.
• Possess adequate knowledge of Medicare and insurance standards to ensure reimbursement for all services rendered.

• Must pass a criminal background check.
• Must pass a drug test.
• Must have the ability to fill out and turn in a time sheet in a timely manner.
• Must have respect and take care of company technology placed in your care.

• Advanced written and verbal communication skills.
• Organizational and time management skills.
• Ability to supervise in accordance with agency policies and applicable laws.
• Ability to respond to common inquires or complaints, regulatory agencies or members of the business community.
• Have friendly and cooperative attitude with patients, family and staff.
• Must be able to contribute to the quality of care being rendered through constructive communication with…