Registered Nurse; RN Case Manager II - Home Care

Job Title: Registered Nurse Case Manager II

Department: INT West Monroe

Location: Rochester Regional Health Home Care - 330 Monroe Avenue, Rochester, NY 14607

Hours Per Week: 40

Schedule: Monday-Friday, Days

The RN Case Manager is responsible for the delivery of comprehensive nursing care to a set of assigned patients at a specific point in time. This involves the assessment of patient and family needs and the development, implementation and evaluation of an appropriate Plan of Care, making changes in response to changing patient needs. The RN Case Manager identifies appropriate interdisciplinary services needed, coordinates those services and supervises Private Duty Nurses (PDN) as applicable.

• Identifies and prioritizes health problems based on assessment
• Develops or implements an interdisciplinary Plan of Care based on the needs identified during the assessment, with input from the patient (and their caregivers as applicable), in collaboration with the attending physician and other care team members
• Manages and coordinates patient care, including clinically complex cases, in a manner which ensures the efficient and effective delivery of appropriate services and community supports
• Exhibits proficiency and accuracy in the completion of comprehensive assessment/documentation, which may include assessments required by payer sources (e.g., Outcome and Assessment Information Set (OASIS), Hospice Item Set (HIS)).
• Plans, organizes and prioritizes care needs for an assigned caseload of patients to ensure their care needs are met and services are delivered according to plan of care
• Communicates all changes in patient status and/or service needs to the appropriate care team member and ensures appropriate action is taken in a timely manner
• Facilitates the development and implementation of patient discharge plans as indicated
• Documents all patient care and coordinating activities per agency standards
• Assesses the need for additional services (aide, therapies, social work or a community service) and obtains orders and arranges care as indicated
• Supervises and evaluates care provided by Licensed Practical Nurses and/or home health aides in the performance of his/her patient care duties
• Works collaboratively with other care team members by communicating all changes in patient status and/or service needs to the appropriate care team member and ensures appropriate action is taken in a timely manner.
• Correctly identifies patient/family risk factors and establishes goals and interventions to reduce/remove risk from the plan of care to enable patients to remain in the least restrictive care setting.
• Coordinate/participate in interdisciplinary team meetings/patient care conferences.
• Patient needs are prioritized; visits outside primary team assignment or geographical area may be required in order to meet patient need
• Practices according to Agency and community standards
• Participates in utilization review and/or continuous quality improvement activities as requested.
• Attends required staff meetings, in-services and/or supervisory conferences.
• Participates in on-call schedule and weekend/holiday schedule as assigned.
• Consistently demonstrates high standards of integrity by supporting the Rochester Regional Health Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other job-related duties as assigned by management.

• Offers process improvement suggestions and participates in the solutions of more complex issues/activities.
• Mentors new staff & assists with coaching whenever necessary.
• Serves as an informal leader, role model and resource to other staff in a positive clinical leadership role.
• Provides consistent positive results of audits.
• Works independently in coordinating and collaborating with members and providers, resulting in improving member and community health.
• Manages more complex assignments and larger caseloads with appropriate utilization of services.

• Level I - Diploma or…