RN Case Manager Home Health

How would you like to work in a place where your contributions and ideas are
valued? A place where you can serve with compassion, pursue excellence and honor
every voice? At Wellstar, our mission is simple, yet powerful: to enhance the
health and well-being of every person we serve. We are proud to have become a
shining example of what's possible when the brightest professionals dedicate
themselves to making a difference in the healthcare industry, and in people's
lives.

Work Shift

Job Summary

The RN Case Manager is responsible for providing and supervising primary care to
approximately 25-35 patients in their home setting. This includes age
appropriate interventions that meet physical, emotional, developmental,
psychosocial and educational needs. The RN Case Manager is responsible for the
coordination of all disciplines throughout the episode of care. The RN Case
Manager communicates with all team members including RNs, LPNs, Therapists,
Social Workers, Home Health Aides, the Physician, patient, family, and other
internal or external individuals to ensure that the patient's plan of care is
appropriately developed, implemented and that goals are met. The RN Case Manager
supervises the LPNs and Home Health Aides throughout the patient plan of care.
The RN Case Manager participates with leadership to develop and implement
processes to continue improvement with patient and agency outcomes.

Core Responsibilities and Essential Functions

DIRECT PATIENT CARE - Assesses, coordinates with other disciplines and manages
patient’s total needs, following physician’s orders, using the nursing process -
Develops patient’s plan of care coordinating with other disciplines - Manages
patient from admission through recerts to discharge and appropriately scheduling
visits per physician’s order: adjust frequency as needed, based on patient
clinical status and MD order - Performs routine and complex nursing procedures
to meet the need of the patient COORDINATION OF SERVICES FOR EPISODE OF CARE -
Revises the plan of care based on patient need within physician orders,
coordinating with other disciplines to ensure goals are met to achieve positive
outcomes prior to discharge - Supervises LPNs and Home Health Aides throughout
the continuum of care. - Develops and supervises the care plan provided to the
Home Health Aides - Reviews Plan of Care for patients with the Manager Home
Health and other team members and support services - Maintains communication
with physician reporting any changes that may affect the patient’s recovery
PATIENT / CAREGIVER EDUCATION Provides patient/caregiver education to develop
and encourage self care to achieve positive outcomes Utilizes both verbal and
written tools to facilitate learning and promotion of independence during
recovery Be aware and report concerns to authorities or agency leadership on any
issues that affect patient or staff safety STAFF EDUCATION AND PROFESSIONAL
DEVELOPMENT - Participates in the orientation and education of new employees as
appropriate - Responsible for attending continuing education and in-services as
directed and needed - Responsible to remain current in clinical knowledge for
the care of the home health patient - Receives training, supervision or
direction from leadership as needed COMMUNICATION - Communicates patient status
changes and lab results to the physician as appropriate. - Participates in care
team conferences - Responsible for checking voice mail box and staff messaging a
minimum of once daily REGULATORY GUIDELINES - Demonstrates knowledge and
appropriate application of CMS/State, and Joint Commission regulatory
guidelines. - Responsible for accurate completion of required OASIS and visit
documentation in the patient’s EMR - Completes all documentation within
established timeframes SUPPORTS AND PARTICIPATES IN PERFORMANCE IMPROVEMENT
ACTIVITIES - Participates in department performance improvement activities (i. e.
chart review, committees, etc.). - Participates in system-wide committees as
requested. - Identifies methods for improving department performance/care. -
Assists in implementing performance improvement opportunities OTHER
RESPONSIBILITIES - Meets established productivity standards - Weekend and call
rotation as required - Perform other duties as assigned by Home Health
Leadership

Required Minimum Education

Graduate of an approved school of professional nursing, Required

Required Minimum License(s) and Certification(s)

Reg Nurse (Single State) 1.00 Required RN - Multi-state Compact 1.00 Required
Basic Life Support 2.00 Required BLS - Instructor 2.00 Required BLS -
Provisional 2.00 Required

Additional Licenses and Certifications

Required Minimum Experience

Minimum 1 year of Medical/Surgical Nursing Required and Home Health, and ICU
experience Preferred and Must possess extremely strong critical care nursing
skills. Required

Required Minimum Skills

Strong critical care assessment and clinical skills required. Positive
leadership, problem solving skills, strong organizational and time management
skills. Strong communication (written and verbal) skills. Ability to write and
follow directions to patient’s homes. Use of Windows based computer, utilizing
home health patient software, email, internet, computer based learning modules,
etc. Good understanding of home health operations, reimbursement, law and
regulatory processes. OASIS knowledge preferred.

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rewarding life. Connect with the most integrated health system in Georgia, and
start a future that gives you more.