Registered Nurse Case Manager

Job Title

Registered Nurse Case Manager - Home Health - Full Time - Sonoma/Napa

The Registered Nurse Case Manager plans, organizes and directs care and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

• Patient Care:
  Completes an initial, comprehensive assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es).
• Provides professional nursing care by utilizing all elements of the nursing process as defined in the state Nurse Practice Act.
• Assesses and evaluates patient status by writing and initiating plan of care; regularly re-evaluates patient and family/caregiver needs; participates in revising the plan of care as necessary; initiates the plan of care and revises as patient status changes.
• Uses health assessment data to determine nursing diagnosis; develops a care plan with goals based on nursing diagnosis, incorporating palliative nursing actions; includes patient and family in planning.
• Initiates appropriate preventive and rehabilitative nursing procedures; administers medications and treatments as prescribed by the physician in the plan of care.
• Counsels the patient and family in meeting nursing and related needs; provides health care instructions per assessment and plan; supports activities of daily living and strives for patient self-sufficiency and comfort care.
• Maintains current documentation in the EMR system according to organization policies/procedures and applicable laws/regulations.
• Coordinates patient care for an assigned caseload as assigned by Clinical Manager/DPCS; may act as Admission Nurse or Case Manager for assigned caseload as needed to coordinate with intake, program staff and management for initial admission/assessment and plan of care.

• Completes and submits accurate clinical notes regarding patient’s condition and care; records pain/symptom management changes/outcomes as appropriate.
• Communicates with the physician regarding the patient’s needs and reports changes in condition; obtains/receives physician orders as required.
• Coordinates with community health-related persons to implement the care plan; teaches patient and family self-care techniques as appropriate; provides medication, diet and other instructions as ordered by the physician; works with the interdisciplinary team.
• Maintains a safe environment for the patient and supports continuity of care with the family/caregiver and hospice interdisciplinary group; attends interdisciplinary group meetings.

• Participates in on-call duties as defined by the on-call policy.
• Ensures arrangements for equipment and necessary items and services are available; supervises ancillary personnel and delegates responsibilities as required.
• Maintains professional knowledge and practice skills through continuing education and in-service classes; fulfills requested and/or accepted case assignments; participates in quality assessment and performance improvement activities.
• Adheres to attendance and reliability guidelines to ensure quality and consistent patient care.

• Graduate of a National League for Nursing accredited school of nursing.
• Current licensure in state of practice and current CPR certification.
• Must possess a valid California Driver’s License with proof of valid auto insurance.

California only:

• May have an RN license and have practiced as an RN for a minimum of one year with prior LVN experience in public health, home care, hospice, hospital or skilled nursing facility.

All States:

• Registered nurses shall have a minimum of (a) one (1) year of experience as a professional nurse within the last three (3) years OR (b) have a baccalaureate degree in nursing from a program accredited by the National League for Nursing and a current RN license. A minimum of two years’ experience, at least one of which is in public health, home care, or hospice nursing is preferred.
• M…