Registered Nurse Case Manager

Title:Registered Nurse Case Manager

Department: Home Care & Hospice

FLSA Status: Non-Exempt

Reports To: Director of Patient Care Services/Clinical Manager

Summary: RN Case Manager (RNCM) conducts comprehensive assessment, plans, organizes and directs and coordinates Home Care services, to meet the needs of patients and families within their homes and communities. In addition, the RNCM educates families and caregivers of the patient on recognizing potential symptoms and providing safe and competent care for the patient. Offers emotional and practical support for both the patient and their family or caregivers.

The RNCM's primary goal is to ensure that every patient in their care receives exceptional care and services.

Essential Functions:

• Maintains good knowledge of and adheres to the agency's policies and procedures, Nursing Practice Act, state and federal Regulations related to home health/hospice services, clinical procedures/protocols and acts upon all the requirements.

• Assumes responsibility for the overall care of assigned patients as a Case Manager, who coordinates patient care services between all disciplines of the healthcare team, including PT/OT, ST and MSW, as well as provides supervision to Certified Home Health Aids (CHHA).

• RN/Case Manager completes initial Comprehensive Assessment of patient and family to determine home care needs. Provides a complete Physical Assessment, including the history of current and previous illnesses, vaccinations, surgeries, etc.

• Requests SOC order from patient's PCP, using SBAR protocol (describing situation/background of the patient, assessment findings and recommendations(order)).

• Documents assessment findings in OASIS, and submits it in the EMR system within 48 hours from the SOC date. Makes sure that all fields of OASIS are completed thoroughly and accurately according to assessed/factual data. After OASIS is validated by QA RN, RNCM completes all requested corrections and re-submits OASIS no later than 24 hours from receiving OASIS back from QA.

• Reconciles all patients' medications and documents them in the patient's Medication Profile during the Initial Assessment Visit. This includes all allopathic and complementary and alternative medicine (CAM), such as, supplements, ointments, gases (Oxygen), and herbals. Conducts drug interaction reaction check, determines severe/moderate drug interaction reaction and duplicated medications. Reports to PCP all significant drug interaction reactions, any unknown CAM products and duplicate findings within 24 hours of SOC visit by phone call, followed by submitting a Physician Order to the office to fax to PCP.

• Develops an initial plan of care under doctor's order.

• Develops an initial Plan of Care and discuss it with the DPCS and/or the Hospice Clinical Team Supervisor (HCTS) and PCP after the SOC visit.

• During the Episode of Care, RN Case Manager evaluates, and revises the patient's individualized plan of care in collaboration with the Director of Patient Care Services and/or the Hospice Clinical Team Supervisor, the Medical Director, other members of the Inter-Disciplinary Group, and the patient's primary care physician.

• Refers patients for other disciplines' evaluation (PT/OT, MSW, ST) and CHHA services as needed, reflecting these referrals in SOC order.

• Develops CHHA Plan of Care and supervises Certified Home Health Aide and licensed vocation nurses (LVN's) not less than every 14 days, as required by Medicare home health and hospice COP's and California Title 22. Provides onsite supervision of LVNs and CHHAs.

• Plans frequencies of visits, with consideration of the complexity of the patient's condition and the patient's treatments/education/services needed. Frequencies of visits are reported to DPCS and/or HCTS for approval. When approved, the frequencies are documented on SOC order and the calendar of visits is completed at the office.

• Assesses patient's needs for DMEs, and requests necessary DMEs in SOC order.

• Reports Start of Care Assessment findings to DPCS and/or HCTS in verbal or written format within 24 hours of completing the Comprehensive Assessment of the patient, including proposed…