RN Case Manager

Responsibilities:

• Conduct comprehensive nursing assessments of patients' physical, emotional, psychosocial, and spiritual needs during admission, resumption of care, recertification, and discharge.

• Develop, implement, revise, and evaluate individualized Plans of Care in collaboration with patients, families, physicians, and the interdisciplinary team (IDT).

• Deliver direct skilled nursing care, including wound care, medication administration and management, IV therapy, injections, symptom management, and patient/caregiver education.

• Perform accurate and timely OASIS assessments to ensure proper reimbursement, quality reporting, and optimal patient outcomes.

• Educate patients and their families/caregivers on disease management, medication adherence, safety measures, self-care techniques, and strategies to prevent re-hospitalizations and promote independence.

• Supervise and direct LPNs/LVNs, home health aides, and other support staff to ensure coordinated, high-quality care delivery.

• Monitor patient progress, promptly identify changes in condition, and adjust care plans accordingly to optimize outcomes.

• Maintain accurate, timely clinical documentation in the Electronic Medical Record (EMR) system in compliance with agency policies, OASIS guidelines, and all regulatory/payer requirements.

• Actively participate in case conferences, interdisciplinary team meetings, and quality improvement initiatives.

• Manage a productive caseload with efficient visit scheduling within the assigned territory while ensuring continuity of care and exceptional patient experience.

• Respond to urgent patient needs and participate in on-call rotations as required.