RN Case Manager

Job Summary:

The RN Case Manager in Home Health provides skilled nursing care by evaluating, treating, and coordinating patient care plans in collaboration with physicians, patients, families, and interdisciplinary teams. This role focuses on comprehensive patient assessment, care planning, education, and communication to support patient health and well-being in a home health setting. The position requires a minimum of two years of home health experience and an active Registered Nurse license in Vermont or New Hampshire. Responsibilities:

• Screen, evaluate, and re-evaluate patients to develop and update individualized care plans.
• Collaborate with physicians, patients, families, and caregivers to create and recertify care plans.
• Coordinate care through interdisciplinary communication and case conferences.
• Provide ongoing assessment of clinical, functional, and emotional patient status to identify problems or progress.
• Communicate significant patient changes to physicians and nursing colleagues promptly.
• Document evaluations, treatment goals, and care objectives accurately and timely.
• Educate patients and caregivers on self-care techniques, medication, diet, and health counseling as ordered.
• Advise other disciplines of patient discharges in a timely manner.

Required Skills & Certifications:

• Active Registered Nurse license in Vermont, New Hampshire, or an unencumbered compact license.
• Graduate of an accredited school of nursing.
• Minimum of 2 years of experience in home health nursing.
• Strong clinical assessment, care planning, and interdisciplinary collaboration skills.
• Excellent communication and documentation skills.

Preferred Skills & Certifications:

• Experience with hospice care or other specialized nursing fields.
• Additional certifications related to case management or home health nursing.

Special Considerations:

• Work involves providing care in patients' homes across multiple towns in Vermont and New Hampshire.
• Requires ability to work independently while maintaining strong team collaboration.
• May require travel within service areas; reliable transportation is necessary.

Scheduling:

• Full-time position with day shifts.
• Schedule supports work/life balance with flexibility to meet patient needs.