Job Description

Position Description

Under the general supervision of the Clinical Supervisor/Clinical Manager, the RN - Case Manager provides intermittent skilled nursing services; communicates the patients progress with other disciplines and directs, supervises and instructs non-professional home health aide staff in the provision of personal care to the patient.

Essential Duties and Responsibilities

* Under the Physicians order, admits patients eligible for home care services within 24-48 hours
* Assesses and evaluates patient needs/problems, identifies mutually agreed upon goals with patients
* Reports patient status and need for other disciplines to agency Clinical Supervisor and referring Physician
* Reports to assigned follow-up Clinician as indicated
* Develops patient care plan that specifically addresses identified patient problems; patient problems and goals
* Updates care plans on an ongoing basis; revises and resolves patient problems and goals as changes occur and/or at recertification
* Completes admission paperwork and patient care plan submitted to Clinical Supervisor per agency policy following the admission including completed and signed admission checklist
* Provides intermittent Skilled Nursing services including assessment, evaluation, procedures, teaching, and training activities as outlined in the patient Plan of Care
* Provides Skilled Nursing visits according to visit schedule and notifies agency of need to alter schedule in any way
* Reports significant findings to patients Physician and Clinical Supervisor as they occur
* Submits completed skilled nursing visit notes; communication notes and home health aide supervisory notes per agency policy on designated days as requested by Clinical Supervisor
* Submits change orders per agency policy
* Performs all OASIS time point assessment per Medicare Criteria and submits recertification paperwork per agency policy and procedure
* Maintains open lines of communications to all members of the continuum of care team.
* Supervises Home Health Aide and license and documents per Medicare criteria and per agency policy and procedure
* Acts as a preceptor in the orientation of new nursing staff as requested
* Attends staff meetings, team conferences and educational in-services per agency requirements
* Participates in Process Improvement (PI) program by assisting with collection of data and serves on PI team upon request
* Participates in discharge planning process Medicare Criteria and agency policy and procedure
* Follows agency policies and procedures
* Performs these and all other duties as assigned by the Administrator
* Able to lift 40 pounds from floor to shoulder
* Repetitive walking, standing, sitting, bending, and use of hands
* Able to drive a car 2-4 hours per day

REQUIRED Knowledge, Skills, and Experience

* Current unencumbered State Professional Nurse License
* Automobile to be used for work, current drivers license, good driving record, and proof of insurance
* The ability to make sound professional clinical judgment
* The ability to assess and document patient needs and formulate individualized patient care plans to meet those needs
* Proficient clinical skills
* Excellent verbal and written communication skills
* Proficiency in personal computer use, including e-mail, clinical, word processing, spreadsheet, and presentation software

Preferred Knowledge, Skills, and Experience

* One year of experience as a home care professional nurse and is competent in performing home care comprehensive assessment