Home Health Registered Nurse Case Manager

Assumes responsibility for caseloads consisting of patients in specialty areas. Conducts initial assessment to obtain thorough physical, social and environmental data. Establishes the plan of care in accordance with the physician orders and patient needs. Provides direct patient care and adjusts nursing care processes as needed. Identifies problems, modifies nursing care plan, and evaluates outcomes within an appropriate time frame. Advises and consults with family and other personnel, as appropriate. Provides on-going assessment of patient response to treatments and teaching and applies interventions as appropriate. Updates and revises plan of care as indicated. Completes documentation including visit assessment, OASIS, 485 and verbal orders accurately and promptly and within the standards. Communicates with physicians to confirm and update patients\' plan of care. Provides status updates and ensures ongoing communication with the physician and other members of the health care team. Facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge. Participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate. Participates in chart audits and continuous quality improvement activities as requested. Identifies, develops and participates in process improvement opportunities that will enhance the quality of the services provided. Maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient\'s status and interpret the appropriate information needed to identify each patient\'s requirements relative to his/her age-specific needs, and to provide the care needed as described in the department\'s policies and procedures. Age-specific information is developed further in the departmental job standards. Major Responsibilities Assumes responsibility for caseloads consisting of patients in specialty areas. Conducts initial assessment to obtain thorough physical, social and environmental data. Establishes the plan of care in accordance with the physician orders and patient needs. Provides direct patient care and adjusts nursing care processes as needed. Identifies problems, modifies nursing care plan, and evaluates outcomes within an appropriate time frame. Advises and consults with family and other personnel, as appropriate. Provides on-going assessment of patient response to treatments and teaching and applies interventions as appropriate. Updates and revises plan of care as indicated. Completes documentation including visit assessment, OASIS, 485 and verbal orders accurately and promptly and within the standards. Communicates with physicians to confirm and update patients\' plan of care. Provides status updates and ensures ongoing communication with the physician and other members of the health care team. Facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge. Participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate. Participates in chart audits and continuous quality improvement activities as requested. Identifies, develops and participates in process improvement opportunities that will enhance the quality of the services provided. Maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines. Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient\'s status and interpret the appropriate information needed to identify each patient\'s requirements relative to his/her age-specific needs, and to provide the care needed as described in the department\'s policies and procedures. Age-specific information is developed further in the departmental job standards. Licensure, Registration, And\/or Certification Required Registered Nurse license issued by the state in which the team member practices, and Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required, and A valid drivers license issued by the Division of Motor Vehicles Education Required Associate\'s Degree in Nursing. Experience Required Typically requires 3 years of experience in clinical nursing. Knowledge, Skills & Abilities Required Excellent communication skills. Strong interpersonal skills and the ability to work with a variety of clients with patience and respect. Good organizational, analytical and problem solving skills. Demonstrated ability to work well with physicians and other professionals in a direct and positive manner. Proficiency in clinical skills with the ability to work under direction and make sound judgments. Ability to operate the necessary equipment to perform the job, i.e., FAX, computer, copier, telephone system. Ability to assess data reflecting the patient\'s status and the ability to interpret the appropriate information needed to identify each patient\'s requirements relative to their specific needs. Must have a tolerance for differences and an appreciation of multi-culturalism and diversity of the patients and their families. Physical Requirements And Working Conditions Must be capable of the manual dexterity required to use and operate a variety of equipment. Must have the physical ability to move about in confined spaces, including bending, twisting, kneeling, squatting and occasionally reaching one or both arm overhead. Must be able to work safely with people of various sizes and weight with diverse and complex medical conditions and physical limitations. Must be able to sit, stand, walk and climb stairs for limited to prolonged periods of time to complete required paperwork, gain entry to patients’ residences, travel from assigned visits and attend a variety of work related activities. Must have the physical stamina to attend to patient care requirements over a period of three or more hours without complete rest. Must have accurate vision to read gauges and measuring devices and to interpret written instructions. Subject to extreme temperature changes due to weather conditions. Subject to exposure to chemical and hazardous waste and communicable disease. Must be able to: Lift up to 50 lbs from floor to waist. Lift up to 20 lbs from waist to overhead. Lift and carry up to 40 lbs. at waist height reasonable distance. Must be able to: Push\/pull with 30 lbs. of force. Perform a sliding transfer of 150 lbs. with a second person present. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. #J-18808-Ljbffr