Nurse Case Manager

Job Title

Responsible for nursing assessment, writing of diagnoses, developing and intervening in the persons receiving services health care plans to ensure quality care in the most efficient manner. Advocates for health and accesses hospital and specialty clinic services. Provides supervision to the Licensed Practical Nurse(s) on shift.

Position Duties

• Assesses each person receiving services to determine and identify needs, issues, resources, and health care outcomes. Identifies individual's development strengths and health care needs. Obtains emergency medical care when necessary.
• Develops and updates health care plan to address assessed needs. Provides direct medical/nursing services to assigned individuals as presented.
• Oversees the implementation of the health care plan by training persons receiving services, family, and/or caregivers. Trains and oversees staff in carrying out treatment plans relating to health needs on an ongoing basis.
• Evaluates effectiveness of plan in meeting outcomes. Communicates outcomes to patients, families, caregivers, or service providers.
• Refers to other health providers, as needed. Schedules follow-up medical appointments according to medical recommendations.
• Ensures proper documentation of persons receiving services care and progress. Details acute and chronic health problems and interventions; reviews, medication, hospitalizations, clinics, weights, and dietary concerns.
• Identifies the need for, and arranges and conducts conferences to facilitate resolution of complex issues. Consults with Charge Nurse and/or Nursing Supervisor, as needed.
• Maintains ongoing communication with attending physicians, supervisors, and other health care practitioners (Clinicians).
• Works collaboratively with all involved personnel in managing the person receiving service's care from admission through discharge.
• May accompany persons receiving services to clinics, recreation outings, social outings, etc.
• Develops strategies to prevent acute hospital admissions and/or deteriorations.
• Reviews incoming clinic visit summaries and chart in progress notes the results of doctor visits then implements orders in a timely manner.
• Develops and updates patient's profile with the Residential Coordinator or other service providers for use at clinic appointments and hospitals, to include presenting problems and current medication list.
• Conducts on-going reviews of medication administration documentation and monthly reviews of medexes.
• Conducts regularly scheduled observations and pouring (procedures) of medication administration procedures performed by medication certified personnel.
• Regularly reviews procedures for medication receipt storage or accountability with Charge Nurse providing assistance in implementing corrective action as necessary.
• Provides direct oversight to Licensed Practical Nurse on shift, reporting problems and corrective action to Charge Nurse.
• In the absence of the Residential Coordinator and/or Shift Supervisor, directly supervises Direct Care staff for all individual care responsibilities.
• Maintains close contact with individual's Day Program Nurse to ensure all medical/nursing needs are met in the Day Program. Provides health assessments and doctor's orders where needed.
• Performs all other duties as assigned.

Requirements

• NYS Licensed Registered Nurse (BSN minimum).
• Minimum 2 years experience working with persons with disabilities.
• Extensive knowledge of pertinent health resources.
• Excellent oral and written communication skills.
• CPR Certification.
• Performs all job responsibilities in full compliance with all applicable laws, rules, regulations, policies and procedures. Adheres to the agency's corporate compliance program, including the code of business conduct, the NYS and federal false claims acts, whistleblower protections and mandatory reporting. Completes corporate compliance training at least annually. Fully cooperates in all corporate compliance investigations and reviews.

Constructive Partnerships Unlimited