Home Health Care Manager, RN

DCH Health System•Tuscaloosa, AL

2d•Onsite

About The Position

The RN Care Manager manages all aspects of patients’ home health care from start of care through discharge, collaborating with team visit nurses and other disciplines based on patient needs. The role determines patient eligibility, completes most OASIS assessments, and develops individualized, evidence-based care plans in accordance with professional standards, Agency policies, and State and Federal laws and regulations. The RN Care Manager contributes to quality and process outcomes and maintains responsibility for assigned patients and coordination of their care.

Requirements

Current Alabama Registered Nurse license.
At least one year of registered nurse clinical experience.
Current BLS certification, or ability to obtain it within 60 days of employment and before the first independent patient visit.
Excellent coordination and communication skills.
Detail-oriented and able to work with minimal supervision.
Able to read, write legibly, speak, and comprehend English.
Licensed and insured to operate a motor vehicle.
Able to perform the duties with or without reasonable accommodation.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Extensive clinical knowledge and experience caring for patients with multiple and complex diagnoses, disease processes, and care needs preferred.
Working knowledge of OASIS preferred.
Working knowledge of computer systems preferred.

Responsibilities

Continuously review assigned patients’ care, including service utilization, skilled-care needs and homebound status, safety, medications, medical-record documentation, interdisciplinary communication, and discharge planning.
Complete initial patient and family assessments, including a physical assessment and history of current and previous illnesses, to determine home care needs.
Explain patient rights and expectations, HIPAA confidentiality, OASIS data, advance directives, expected disciplines, and visit frequency; review changes throughout the episode of care.
Develop and revise plans of care that align with physician orders and nursing diagnoses, establish goals, and incorporate therapeutic, preventive, and rehabilitative nursing actions, involving the patient and family in planning.
Communicate with and update the primary physician as needed and at least every 60 days.
Reassess patients within 24–48 hours after a change in condition or discharge from an inpatient setting and update the plan of care.
Use health assessment data to determine nursing diagnoses.
Establish working relationships with physicians and their office staff and keep them informed of patient problems and progress as appropriate.
Counsel and instruct patients and families on nursing and related needs.
Provide quality patient care.
Supervise LPNs and home health aides in accordance with regulatory requirements.
Schedule patient care efficiently in collaboration with team visit nurses and other disciplines.
Present patients at interdisciplinary team (IDT) conferences.
Rotate night, weekend, and holiday call to provide patient coverage.
Support and promote Agency policies and practices and maintain communication with team members.
Maintain nursing competencies through Agency education and training and independent study.
Attend mandatory Agency meetings and in-services.
Participate in assigned Quality Improvement, Corporate Compliance, and chart-audit activities.
Meet the daily average productivity standard.
Meet performance, patient and employee satisfaction, and financial standards outlined in the performance evaluation.
Perform compliance requirements and adhere to DCH Behavioral Standards and all DCH Health System policies and procedures.
Perform essential functions in a way that supports safety; identify and reduce unsafe practices and take appropriate action to reduce risks and hazards.
Use electronic mail, time and attendance software, learning management software, and the intranet.
Perform other duties as assigned.