Home Health

Home Care Nurse (Case Manager)

The Home Care Nurse (Case Manager) provides one-on-one care and assesses the effectiveness of the treatment to ensure that the patient receives the most comprehensive, high-quality, and appropriate care possible. They work in a multidisciplinary team that includes: Medical Doctors; Physical, Speech and Occupational Therapists; Medical Social Workers; and Home Health Aides.

Primary Accountabilities:

• Performs complete comprehensive Assessment at every patient visit, to include but not limited to psychosocial, safety, and risk factors.
• Performs accurate OASIS Assessment time points such as SOC, ROC, Recertification, Transfer and Discharges, to ensure quality patient outcomes.
• Maintains compliance to State/Federal Home Care rules and regulations and TJC standards of reference in the delivery of Home Care Services.
• Participates in Performance Improvement processes by reviewing medical records on a regular basis as assigned.
• Participates in the team interdisciplinary case conferences on a regular basis as determined by the PI Supervisor.
• Coordinates and ensures delivery of care based on individual patient goals within the Plan of Care.
• Coordinates effective Discharge planning with the Clinical Team to include following patients progress toward goals as set for patient episode of care, physician notifications of progress toward goals and outpatient referrals as appropriate, to meet patients' needs outside of Agency scope of practice.
• Demonstrates commitment to the Clinical Team with regard to maintaining continuity of care within the agency census.
• Demonstrates professionalism by exhibiting dependability, reliability and flexibility with a focus on a Team Approach to patient care.
• Demonstrates effective medication administration provided to patients as evidenced by Field Supervisory/Infection Control Evaluations, and Clinical Practice.
• Demonstrates effective communication with other members of the Clinical Team and promotes a cohesive multi-disciplinary approach to patient care.
• Utilizes Health First Home Care computer systems with regards to all aspects of communication and documentation as set forth by Agency Policies, MCR/TJC requirements for patient care in the home setting.
• Adheres to all Health First, Inc. and all Health First Home Care policies and procedures.
• Demonstrates effective and safe clinical practice as evidenced by Field Supervisory/Infection Control Evaluations, completion of yearly Competency Assessment, and Age Specific Checklist.
• Documents all patient care, exacerbation or progress toward goals as set for patient episode of care, physician notifications and referrals to meet patients needs outside of Agency scope of practice.
• Demonstrates commitment to the clinical Team with regard to maintaining continuity of care within that Teams patient census.
• Assists with the Orientation process of new associates and staff education.
• Complies with State and Federal Regulations, TJC standards in reference to delivery of Home Care Services.
• Actively participates in Quality Improvement processes, including peer chart reviews and self-chart reviews.
• Supervises the Home Health Aide at least every 14 days, and supervises the Licensed Practical Nurse (LPN) at least every 30 days.
• Communicates effectively with discipline to provide continuity and comprehensive care.
• When needed, assists the Weekend Staff for coverage to maintain continuum of care.
• Participates in agency on-call as defined.
• Provides service to patients and families with sensitivity and respect for their needs, expectations, age, cultural, and individual differences.
• Contributes to the patient experience as evidenced by positive patient satisfaction scores and HHCAHPs scores for department or written compliments by patients/others as well as consistent performance of purposeful skilled RN Home Visits.
• Informs patient/family of visit schedule in advance by calling the night before and/or if schedule changes.

Work Experience

• Must be able to work at multiple locations throughout Brevard County, FL.
• Graduate of an approved school of professional nursing.
• Current Florida RN licensure or endorsement.
• Current AHA BLS Healthcare Provider Completion Card.
• Current Florida Drivers License, automobile insurance and reliable transportation.
• Proficient Computer skills.
• Must have 1 year of acute care nursing experience.
• IV Therapy and phlebotomy experience required.

Schedule: All

Shift Times: 8:00am-5:00pm

Paygrade: PG-29R RN-3