Case Manager-1

Team Select Home Care•Boston, MA

23h•Onsite

About The Position

The Case Manager is a qualified registered nurse responsible for providing and overseeing the care of assigned patients and associated staff. This role involves developing, implementing, and evaluating individualized patient-centered care plans in accordance with physician orders and state Practice Acts. The Case Manager acts as an advocate for patient welfare, coordinating care between patients, families, agency staff, and other healthcare providers. Key responsibilities include accurate data collection (OASIS, PAR), initial evaluations, regular reevaluations of patient needs, and furnishing services requiring specialized nursing skills. The position requires strong problem-solving and interpersonal communication abilities, identifying patient care preferences, and ensuring interventions meet patient goals. The Case Manager prepares clinical notes, attends case conferences, and informs physicians of patient status changes. They also counsel patients and families on home health strategies, administer medications, process orders, and refer patients to other therapy services as needed. Adherence to agency policies, infection control, and quality assurance is crucial. This role also involves on-call duties, including nights, weekends, and holidays, where the RN acts as an after-hours supervising nurse, making assessment and triage decisions. The Case Manager is responsible for maintaining patient confidentiality, submitting documentation promptly, and ensuring patients/caregivers receive written instructions regarding their care schedule, medications, and treatments. All other duties as assigned are also part of this role.

Requirements

Qualified registered nurse
Average computer skills with competency in media communications
Must have the physical abilities to perform the described duties
Able to organize work procedures through time management, assume responsibility and effectively supervise ancillary disciplines per state requirements
Able to secure transportation and travel as required
Able to apply professional training to critically think through patient needs, follow physician’s orders and produce accurate records of nursing activity within agency guidelines
Acceptance of philosophy and goals of this Agency
Ability to exercise initiative and independent judgment
Able to meet all health requirements for clearances and for current CPR
Able to maintain licensure and continuing education as applicable
Excellent verbal and written communication
Graduate of an approved school of professional nursing and currently licensed in the state(s) in which practicing
Minimum (1) year nursing experience required

Nice To Haves

Prior home health experience preferred

Responsibilities

Develops, delivers/implements, revises, and evaluates individualized patient-centered care plans under the supervision of a physician
Provides case management to an assigned group of patients and ancillary staff
Understands and submits required data collection sets (OASIS, PAR, etc.) and other documentation as requested by the state and/or, federal government and insurance payers within required timeframes
Makes the initial evaluation visit and regularly reevaluates the patient’s nursing needs per state and payor requirements
Acts as an advocate for patient welfare and coordinates care between patients, their families/caregivers and/or their authorized representative, the agency and other healthcare providers/facilities/ outside agencies
Furnishes those services requiring substantial specialized nursing skill according to competency level
Demonstrates problem solving abilities and positive interpersonal communication skills
Identifies care preferences of patients and verifies that interventions meet the patient’s needs and their goals of treatment
Initiates appropriate preventive and rehabilitative nursing procedures
Prepares clinical and progress notes for each patient visit and summaries
Attends case conferences as assigned
Informs physician and other personnel of changes in the patient’s condition and needs
Counsels the patient and family/significant others in meeting nursing and related needs. Educates on the proper home health strategies and procedures utilizing community resources as applicable
Observes and reports patient symptoms, reaction to treatments, drugs and changes in the patient’s physical or emotional condition, responsible for medication reconciliation
Participates in in-service programs, supervising and teaching other nursing personnel as assigned
Administers medication per agency policy and physician orders
Provides written instructions for aides or other ancillary disciplines caring for the patient
Processes orders and notifies physician of patient needs and changes in condition
Refers cases with physician’s orders to Physical Therapist, Speech Language Pathologist, Occupational Therapist and Medical Social Worker for those patients requiring their specialized skills
Understands and adheres to the Policy/Procedure, Best Practices, Infection Control Plan, EMS Plan, and the Compliance Plan
Participates in clinical record/utilization review of medical records and quality assurance and performance improvement (QAPI) quarterly and as assigned.
Reports/records all applicable infections, occurrences, and complaints
Submits documentation within 24 hours or per state requirements
Maintains confidentiality of patient, employee, and agency matters
Takes on-call duty nights, weekends, and holidays, as assigned. When functioning as the on-call RN acts as the after-hours supervising nurse and makes nursing assessment and triage decisions under the guidance of the overall Clinical Supervisor as applicable
Immediately reports to Nursing Supervisor any patient incidents/variances or complaints
Demonstrates competent performance of technical skills according to established procedures
Maintains acceptable attendance status, per Agency policy
Reports all incomplete work assignments to Nursing Supervisor
Demonstrates effective time management skills through daily documentation and infrequent overtime for routine assignments
Ensures that the following information/instruction is given in writing to the patient/caregiver/representative: visit schedule with frequency of visits, complete medication profile, any treatments to be administered by agency staff (POC), any other pertinent instruction related to the patient’s care needs, name and contact information of the agency’s Clinical Manager
Performs all other duties as assigned