Home Health Care Manager, RN

DCH Health Care Authority•Tuscaloosa, AL

1d•Onsite

About The Position

The RN Care Manager manages all aspects of patients’ home health care from the start of care through discharge, in collaboration with team visit nurses and other disciplines. The role determines patient eligibility for care, completes most OASIS assessments, and develops evidence-based, individualized 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 is responsible for coordinating safe, effective care for assigned patients. The position requires ongoing review of patient status, services, skilled-care needs, homebound status, safety, medications, medical-record documentation, interdisciplinary communication, and discharge planning. The RN Care Manager assesses patients and families, develops and revises plans of care with patient and family involvement, coordinates with physicians, counsels and instructs patients and families, provides patient care, and supervises LPNs and home health aides as required. The role also includes patient conferences, rotating night, weekend, and holiday call, education and training, quality-improvement and compliance activities, chart audits, and meeting productivity and performance standards. The position requires physical presence onsite and use of electronic mail, time and attendance software, learning management software, and the intranet. The RN Care Manager must comply with DCH Health System policies and procedures and perform duties in a manner that promotes patient, visitor, and employee safety.

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 lift 50 pounds and turn and position patients weighing over 200 pounds.
Able to stand, walk, kneel, sit, crouch, or stoop with good balance for extended periods.
Able to maneuver over uneven surfaces, including fields, grass, ditches, gravel, concrete, wood, vinyl, and carpet.
Good manual finger dexterity.
Able to tolerate varied environments, including the presence of pets and infestation.
Normal hearing and vision, or corrected to within normal range.
Able to perform duties with or without reasonable accommodation.

Nice To Haves

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

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 assessments of patients and families to determine home-care needs, including a physical assessment and history of current and previous illnesses.
Explain patient rights and expectations, HIPAA confidentiality, OASIS data, advance directives, and expected disciplines and visit frequency to patients and families.
Review changes in patient status throughout the episode of care.
Develop and revise individualized plans of care that correspond with physician orders, establish goals based on nursing diagnoses, and incorporate therapeutic, preventive, and rehabilitative nursing actions.
Include patients and families in care 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 toward goals as appropriate.
Counsel and instruct patients and families in meeting nursing and related needs.
Provide quality patient care and supervise LPNs and home health aides according to regulatory requirements.
Maintain responsibility for assigned patients and schedule care efficiently in collaboration with team visit nurses and other disciplines.
Present patients at interdisciplinary team (IDT) patient conferences.
Rotate night, weekend, and holiday call to support patient coverage.
Support and promote Agency policies and practices and maintain communication with team members.
Maintain professional competencies through Agency education and training and independent study.
Attend mandatory Agency meetings and in-services.
Participate in assigned Quality Improvement and Corporate Compliance activities and chart audits.
Meet the daily average productivity standard and performance, patient and employee satisfaction, and financial standards outlined in the performance evaluation.
Follow Employee Handbook requirements, DCH Behavioral Standards, and DCH Health System policies and procedures.
Perform essential functions in a way that ensures safety, identifies unsafe practices, and reduces risks and hazards for patients, visitors, and employees.
Use electronic mail, time and attendance software, learning management software, and the intranet.
Perform other duties as assigned.