Registered Nurse Case Manager

Job Summary To provide prescribed nursing care services to the ill, injured, convalescent and disabled persons in the home care setting by following a Plan of Care (POC) according to the patient's needs. This includes comprehensive health and psychological evaluation, monitoring of the condition, health promotion and prevention, coordination of services, teaching and training activities, and direct nursing care. Essential Functions Must use the ability to transfer scientific knowledge from social, biological and physical sciences in the application of the nursing process. Responsibilities Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet. Evaluate the patient, family members and home to determine necessary health teaching. Evaluate the patient's environment to determine whether assistance will be available from family members caring for the patient. Perform accurate assessments, develop and implement a written Plan of Care with the patient following physician's orders and according to agency guideline; perform and document nursing interventions including patient education and adapt actions as patient needs change. Demonstrate knowledge and competency in performing baseline nursing skills as outlined in agency policy and clinical policy; maintain clinical competencies according to hospice care standards and comply with state practice act. Provide head‑to‑toe nursing assessment and create a summary of the work performed; certify patient's homebound status by following Medicare guideline and indicate the level of supervision required thereafter. Document patient status in an accurate and concise manner as required by agency policy; address patients' needs and problems, nursing interventions, patient response, safety interventions and education. Submit clinical notes no later than 48 hours after the visit. Evaluate the effectiveness of nursing service to the patient and the family on an ongoing basis. Perform admission, transfer, re‑certification, resumption of care and discharge skilled nurse visits for the home care patient. Assist the agency by performing orders such as assessments, wound care, lab draws, IV's, etc. Administer all medications and treatments according to agency policy, accepted standards of care and home care guidelines. Communicate effectively with other nurses, patients, families and physicians; document patient status, patient needs/problems, nursing interventions, patient response, safety interventions and education/training. Discuss with the appropriate supervisor the need for the involvement of other members of the hospice team such as the Hospice Aide, the Physical Therapist, the Speech Therapist, the Occupational Therapist, the Medical Social Worker, etc. Demonstrate organization and leadership abilities by effective use of time and personnel through supervision and teaching; establish priorities and delegate responsibilities appropriately when supervising the LPN and HHA. Maintain a committed and cooperative attitude with staffing, promote teamwork and harmony by readily assisting other staff and patients, and participate in case conferences/team meetings. Makes visits as scheduled and participates in on‑call rotation as required. Work independently without on‑site supervision and submit a tally of patient care visits made each day along with an accurate timesheet. Additional Responsibilities Conforms to all applicable Agency policies and procedures. Performs related duties as assigned or requested. Continually strive to improve nursing care by attending in‑service education, formal education, workshops, conferences, setting goals, active participation in professional and related organizations, and individual research. Assumes accountability for reporting incidents and complaints according to Agency policy. Possess adequate knowledge of Medicare and insurance standards to ensure reimbursement for all services rendered. Necessities Must pass a criminal background check. Must pass a drug test. Must have the ability to fill out and turn in a timesheet promptly. Must respect and take care of company technology placed under your care. Knowledge/Skills/Abilities Advanced written and verbal communication skills. Organizational and time management skills. Ability to supervise in accordance with agency policies and applicable laws. Ability to respond to common inquiries or complaints, regulatory agencies or members of the business community. Friendly and cooperative attitude with patients, family and staff. Contribute to the quality of care rendered through constructive communication with nursing managers and staff. Use critical thinking to resolve problems. Technology/Equipment Operation Interact with a computer to check email, assess training and review your schedule. Interact with an iPad for onsite charting and documentation. Instruments and equipment used on a regular basis: Thermometer, blood pressure cuff, glucometer, PT/INR machine, PICC line, wound vac; IV skills competency will be evaluated upon hire. Job Conditions Must have a driver’s license and be willing to drive to a patient’s residence within a 50‑mile radius of the current TruHeart Office (2738 East 51st St, Ste 24, Tulsa, OK 74105). Frequent communication by telephone and in writing is required. Access a patient’s home, which may not be routinely wheelchair‑accessible. Hearing, eyesight and physical dexterity must be sufficient to perform a physical assessment and to perform patient care. Physical activities will include walking, sitting, stooping, standing and lifting patients; environments may be less than ideal. Information Management Has access to all patient medical records for discussion with the supervising nurse. Treats all information and data within the scope of the position with appropriate confidentiality and security regarding patients and business trade practices. Maintains patient rights and dignity through HIPAA compliance. Age Related Competencies Demonstrate basic knowledge and skills necessary to identify age‑specific patient needs appropriate for this position. Risk Management Cooperate fully in all risk management activities and investigations. Keep abreast of changes in health care law. Maintain agency/program compliance with local, state and federal laws as well as state accreditation standards. Minimum Position Qualifications Education: Graduate of an accredited school of nursing for RN. Experience: One or more years in home health agency or in hospital setting. Training: Competency assessments must be completed. License/Certification Current Oklahoma RN license, CPR, driver’s license and auto insurance. Work Attire Scrubs. Environmental Conditions Moderate noise level; inherent potential for exposure to bloodborne pathogens, moderate stress and emotional demands. Physical Requirements Sitting (3‑6 hours daily). Standing (occasionally 3 hours or less daily). Walking (occasionally 3 hours or less daily). Twisting (occasionally 3 hours or less daily). Bending (occasionally 3 hours or less daily). Squatting/Kneeling/Crawling/Climbing (occasionally 3 hours or less daily). Wrist deviation side to side (occasionally 3 hours or less daily). Hand/Wrist repetitions up and down (occasionally 3 hours or less daily). Reaching (occasionally 3 hours or less daily). 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