The Case Manager plans, organizes and directs home care services. This RN initiates the plan of care and makes the necessary revisions as the patient status and needs change. Oversees the care of the patients, coordinates nursing visits, serves as a resource to other staff, and discharges patients once the plan of care has been met.
- Responsible for the oversight and delivery of competent, quality, patient-centered care rendered in the patient's residence.
- Initiates, develops, implements and revises the patient Plan of Care (POC) as needed.
- Performs a comprehensive physical assessment and history of current and previous illnesses each visit as appropriate including a complete medication review with appropriate education.
- Provides services and/or treatments requiring substantial and specialized nursing skill (within scope of practice) as defines by the State Nursing Practice Act, agency policies and patient plan of care.
- Develops, initiates and revises the plan of care, in consultation with the patient, physician/practitioner and other team members as appropriate, which establishes patient-specific goals and incorporates therapeutic, preventative and rehabilitative nursing services as appropriate.
- Coordinates patient's plan of care in collaboration with other disciplines. Communicates necessary revisions to patient status and/or needs (this includes updating physician facilitating the coordination of services and referrals to other services as appropriate).
- Regularly consults, advises and reevaluates patient status with patient, family, patient representative and other team members as appropriate regarding safety, plan and outcome of care and discharge planning
- Provides education to patient and/or caregiver/representative regarding treatment and changes to the plan of care. Education will utilize terms and teaching methods that are customized to the learning needs of the patient and/or caregiver.
- Provides complete, accurate and timely documentation consistent with the plan of care (this may include preparing clinical, progress and scheduling notes and orders as appropriate). Documentation to be completed within the timeframes designated by Medicare requirements and the organization's documentation expectations.
- Performs supervisory visits of LVNs, Home Health Aides and paraprofessionals providing care to the patient as appropriate including assisting with staff supervisory visits.
- Communicates and documents all scheduling changes and changes in patient conditions to the office in a timely manner to assure follow-up. Responds to messages in a timely manner during scheduled work hours.
- Participates in team meetings, quality improvement teams and in-service programs as required
- On-Call and weekend shift coverage as needed.
- Performs other duties as assigned.
- High School Diploma or equivalent required. Current California RN License.
- Minimum of 1 to 2 years recent acute care experience required. Minimum of 2-5 year in Home Health preferred.
- Basic computer skills.
- Ability to manage time and stay organized. Excellent assessment and nursing skills.
- Good communication skills, detail oriented, critical thinking and problem solving skills. Excellent customer service and telephone etiquette skills.
- BLS required within 60 days of hire.
- Driving required. Current California Driving License and proof of insurance.