Case Manager

Team Select Home Care•Santa Ana, CA

3d•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, managing cases, and ensuring accurate data collection and documentation. The Case Manager acts as a patient advocate, coordinating care between patients, families, the agency, and other healthcare providers. They administer specialized nursing services, provide counseling and education on home health strategies, and maintain detailed clinical notes. This position also involves participating in case conferences, informing physicians of patient changes, and referring patients to other therapy services as needed. Adherence to agency policies, quality assurance, and infection control is crucial. The role includes on-call duties, reporting incidents, and maintaining patient confidentiality. Effective time management and communication are essential for routine assignments and infrequent overtime.

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.