RN - Case Manager

RN, Care Manager (Home Health)

Plans, organizes, and directs home care services to meet the needs of patients in their homes. Manages a patient caseload in an effective and efficient manner. Provides patient care independently, but also collaborates with other core disciplines in accordance with the patient's plan of care to meet care goals. Functions as a resource to patients, family members, and other care team members. Completes initial and ongoing comprehensive assessments of the patient's needs at appropriate time points as assigned. Completes the nursing assessment of assigned patients. Demonstrates ability to discuss and/or teach pertinent aspects of nursing care and patient rights and responsibilities. Identifies and reports problems, abnormal findings, or nursing diagnoses that need follow-up. Implements plan of care in accordance with identified needs. Participates with the patient in clarifying mutually agreed-upon goals and incorporates these goals into the plan of care. Provides direct and/or indirect skilled, safe, quality care. Coordinates patient care with other disciplines and integrates input from disciplines. Performs ongoing nursing assessments and changes plans of care as needed. Accurately completes and legibly documents all pertinent information in accordance with established policies and procedures. Documents patient care delivery, patient status, patient response to treatment, and therapeutic interventions. Ensures that all documentation is completed and submitted in a timely manner. Updates nursing plans and medication profiles when changes occur. Counsels and educates the patient and family in meeting healthcare and related needs. Provides learning opportunities for patient and caregiver, including written material as appropriate. Initiates appropriate preventative and rehabilitative nursing procedures. Complies with all applicable legal requirements, standards, policies, and procedures including the code of conduct. Demonstrates professional conduct, service excellence, and commitment to the mission and values of the organization. On-call duties will be assigned based on operational needs. Performs other job-related duties as assigned. Organizational requirements include receiving all required vaccinations as a condition of employment. Medical and religious exemptions may apply.