Registered Nurse Case Manager, Home Health

Job Description Summary

The Registered Nurse Case Manager plans, organizes, and directs home care services. RNCM is an experienced nurse with an emphasis on community health education or home health. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of the individual and their family within the home setting. The Registered Nurse Case Manager respects and promotes the mission, vision, and values of VNA Health.

Essential Job Duties and Responsibilities

1. Responsible for continuous review of all aspects of every patient on his/her caseload to include: appropriate utilization of services; ensuring continued skilled need; monitoring of homebound status; review of documentation in the medical record; maintenance of interdisciplinary communication and discharge planning.

2. Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es). Admits to appropriate level of service/ care

3. Uses health assessment data to determine nursing diagnosis.

4. Initiates the plan of care and makes necessary revisions as patient status and needs change.

5. Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.

6. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.

7. Regularly re-evaluates patient nursing needs.

8. Counsels the patient and family in meeting nursing and related needs.

9. Provides health care instructions to the patient as appropriate per assessment and plan.

10. Provides supervision of LVN’s and home health aides per accreditation standards and regulatory requirements.

11. Responsible to reassess the patient within 24 hours following a change in condition or discharge from an inpatient setting. Case manager should be the first RN to visit the patient status post hospitalization; updates the plan of care.

12. Accountable for financial resources and eligibility under various third party payor sources, Medicare and Medical.

13. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.

14. Knowledge of state, federal, local and accreditation regulations pertaining to the delivery of home health services.

Communication

1. Prepares clinical notes and updates the primary physician when necessary and at least every sixty days.

2. Communicates with the physician regarding the patient’s needs and reports and changes in the patient’s condition; obtains/receives physician’s orders as required.

3. Communicates on a regular basis with the team and the area team leader.

4. Communicates with community health related persons to coordinate the care plan.

5. Teaches the patient and family/ caregiver self-care techniques as appropriate provides medication, diet and other instructions as ordered by the physician. Recognizes and utilizes opportunities for health counseling with patients and families/ caregivers.

6. Provides and maintains a safe environment for the patient.

7. Assists the patient and family/ caregiver and other team members in providing continuity of care.

Additional Duties

1. Participates in on-call duties as defined by the on-call policy.

2. Actively participates in Quality Management program.

3. Attends and participates in the agency team care conferences.

4. Orients and mentors new staff as requested.

5. Ensures that arrangements for equipment and other necessary items and services are available.

6. Meets daily average productivity standard set by the organization.

7. Assumes responsibility for personal growth and development. Maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job related tasks other than those stated in this description. All clinical staff are expected to participate as needed in variable shifts, including weekend rotation per staffing needs and departmental holiday rotation.

Position Qualifications

1. Current and active California RN license.

2. Bachelor’s degree, preferred.

3. Minimum one year acute care experience required.

4. One year recent home health experience preferred.

5. Current CPR certification.

6. Licensed driver with insured automobile - in accordance with state and/or organization requirements.

7. Management experience not required. Responsible for supervising home health aides/ LVNs.

8. Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.

Physical Requirements

1. Ability to lift 50 lbs.

2. Ability to push/pull 50 lbs.

3. Ability to stoop, bend, and squat.

4. Ability to walk up one flight of stairs.

5. Ability to walk one mile.

6. Ability to sit for one hour, minimum.

7. Visual and audio acuity.

Standard of Performance

VNA Health Evaluation tool.