Registered Nurse​/Case Manager

Must Have Home Health Experience As a Case Manager

Locals Highly Preferred: Must live near the facility.

• CA RN License
• BLS
• Oasis Documentation Experience
• EPIC Experience

We are seeking an experienced RN responsible for the overall management of patients, including the provision of direct care with a designated visit productivity standard. This role involves planning, organizing, and directing all patient care services for patients in the assigned caseload in accordance with current standards and regulations, ensuring the optimal degree of quality care is maintained. The role requires coordinating the interdisciplinary team to implement the established plan of patient care and ensuring effective management of visit utilization and control of expenses.

• Recent experience in home health is required.
• Experience in case management in a hospital setting is not applicable.

This position involves performing routine assignments and developing competence through structured work assignments. The candidate will be accountable for the assessment, coordination, delivery, and evaluation of in-home nursing care, including direct patient care, patient/family education, and transitions of care. The role involves delivering holistic and individualized care to all patients in the assigned area and developing, implementing, managing, and coordinating an optimal interdisciplinary plan of care that incorporates psychological, sociocultural, spiritual, economic, and lifestyle factors.

The candidate will foster and maintain collaborative relationships between patients, their family/support group, physicians, and other healthcare providers through timely and effective communications. Adherence to policies, industry standards, best practices, and applicable laws/regulations and codes is essential to promote a quality, highly reliable patient experience. Continuous growth and development in professional nursing practice are encouraged.

• Conducts patient and family assessments encompassing physiological, spiritual, and emotional areas.
• Collaborates and communicates with physicians and other members of the healthcare team to interpret, adjust, and coordinate in-home patient care plans to ensure a patient-centric plan with continuity of care.
• Partners with peers, other healthcare providers, and management to effectively streamline patient workflow, improve patient outcomes, and provide the highest care quality.
• Communicates patients’ plans of care to co-workers, physicians, and other departments.

• Provides competent, compassionate, and cost-effective patient care in accordance with policies, scientific principles, evidence-based nursing practice/process, nursing objectives, and standard of care.
• Maintains a safe, comfortable, and therapeutic environment for each patient and their families/support group in accordance with regulations.
• Delegates tasks appropriately/effectively to team members based on legal scopes of practice, licensure, educational preparation, appropriate guidelines, and individual capability.
• Communicates with and explains treatments/activities to patients and families in a clear, open-ended, collaborative manner showing care and concern, using teach‑back to ensure patient understanding of explanations, and integrating patient learning and educational needs.
• Maintains mindfulness in the delivery of individualized care and in communication with patients and families, with a safety focus.
• Delivers safe and effective patient care in compliance with established policies and procedures, as well as local, state, and federal regulations to provide the highest level of patient care.
• Upholds the confidentiality of all patient protected health information (PHI) and protects all PHI from accidental, intentional, or inappropriate disclosure.
• Remains current in advancements, trends, and best practices related to acute care and area of specialty and in professional nursing practice.

• Monitors patient care interventions, assesses therapies, evaluates outcomes, and intervenes as warranted.
• Conducts ongoing education for patients and their families to ensure optimal patient care from admission through transitions of care.
• Reassesses, evaluates, and documents each patient’s response to the plan of care and adjusts the plan as needed.
• Reports any events or near-misses in safety or compliance concerns via the patient safety reporting mechanism.
• Participates in the analysis of safety events to prevent future occurrences.
• Accurately documents and updates all treatment information in the patient’s electronic health record (EHR).
• Develops, implements, and documents formal teaching and transition planning that includes the patient/family in care for identified health needs.