RN 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 environment to determine required health teaching and available assistance from family caregivers. Perform accurate assessments, develop and implement a written Plan of Care, and document nursing interventions, 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, maintaining clinical competencies according to home care standards and compliance with the state practice act. Provide head‑to‑toe nursing assessment, certify patient home‑bound status following Medicare guidelines, and indicate level of supervision required. Document patient status accurately and concisely, addressing needs, problems, interventions, patient response, safety measures, and education, with clinical notes submitted no later than 48 hours after visit. Evaluate the ongoing effectiveness of nursing services to the patient and family. Perform admission, transfer, re‑certification, resumption of care, and discharge skilled nurse visits. Assist the agency by performing orders such as assessments, wound care, lab draws, IV access, etc. Administer all medications and treatments in accordance with agency policy, accepted standards of care, and home care guidelines. Communicate effectively with other nurses, patients, families, and physicians, documenting status, needs, interventions, responses, and safety measures. Discuss with the supervisor the need for involvement of other health team members (Home Health Aide, Physical Therapist, Speech Therapist, Occupational Therapist, Medical Social Worker, etc.). Demonstrate organization and leadership by effective use of time and personnel, supervising and teaching, establishing priorities, and delegating responsibilities when supervising LPN and HHA. Maintain a cooperative attitude, promote teamwork and harmony, and assist other staff and patients; participate in case conferences and team meetings. Make visits as scheduled, participate in on‑call rotation, work independently without on‑site supervision, and submit accurate timesheets and daily visit tallies. Additional Responsibilities Conform to all applicable Agency policies and procedures. Perform related duties as assigned or requested. Continuously strive to improve nursing care by attending in‑service education, formal education, workshops, conferences, goal setting, and professional organization participation. Assume 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 Pass a criminal background check. Pass a drug test. Fill out and submit a timely timesheet. Respect and maintain company technology in your care. Knowledge, Skills, and 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 inquiries, complaints, regulatory agencies, or business community members. Friendly and cooperative attitude with patients, family, and staff. Contribute to quality of care through constructive communication with nursing managers and staff. Use critical thinking to resolve problems. Technology and Equipment Operation Must use a computer to check email, complete training, and manage the schedule; interact with an iPad for onsite charting and documentation. Regularly use instruments and equipment including thermometer, blood pressure cuff, glucometer, PT/INR machine, PICC line, wound VAC; IV skills competency evaluated upon hire. Job Conditions Must have a driver’s license and be willing to drive to patient residences within a 50‑mile radius of the TruHeart Office (2738 East 51st Street, Suite 240, Tulsa, OK 74105). Frequent verbal and written telephone communication required. Access patient homes that may lack wheelchair accessibility; hearing, eyesight, and physical dexterity must be sufficient for assessment and care. Physical activities include walking, sitting, stooping, standing, and patient lifting/turning. Work may occur in varied environments with differing cleanliness and comfort levels; be prepared to work under diverse conditions. Information Management Access patient medical records, discussed with supervising nurse; treat all information and data with confidentiality and HIPAA compliance to maintain patient rights and dignity. Age‑Related Competencies Identify age‑specific patient needs and applicable care requirements. Risk Management Cooperate fully in risk management activities and investigations; stay updated on changes in health‑care law and maintain compliance with local, state, federal laws and accreditation standards. Minimum Position Qualifications Education: Graduate of an accredited nursing school (RN). Experience: One or more years in a home‑health agency or hospital setting. Training: Competency assessments completed. License/Certification: Current Oklahoma RN license, CPR, driver’s license, auto insurance. Work Attire Scrubs. Environmental Conditions Moderate noise level; exposure to bloodborne pathogens, moderate stress, and emotional demands. Physical Requirements Sitting (3‑6 hours daily) Standing (Occasionally up to 3 hours daily) Walking (Occasionally up to 3 hours daily) Twisting (Occasionally up to 3 hours daily) Bending (Occasionally up to 3 hours daily) Squatting/Kneeling/Crawling/Climbing (Occasionally up to 3 hours daily) Wrist deviation side to side (Occasionally up to 3 hours daily) Hand/Wrist repetitions up and down (Occasionally up to 3 hours daily) Reaching (Occasionally up to 3 hours daily) Grasping: Simple Pulling (Occasionally up to 3 hours daily) Pushing (Occasionally up to 3 hours daily) Lifts and carries (Occasionally up to 3 hours daily) #J-18808-Ljbffr