Home Health Registered Nurse Case Manager

Alternate Solutions Health Network•North Kansas City, MO

20h

About The Position

The Registered Nurse Case Manager (RNCM) assumes accountability and leadership for assessing patient conditions and developing and overseeing plans of care. The RNCM provides case management and clinical care, and coordinates the disciplines involved in delivering quality, cost-effective, billable care through direct care and supervision under the direction of a physician. The role includes educating patients and family members, promoting patient safety, completing accurate documentation, complying with legal requirements and regulations, and practicing within the scope of practice established by the state. The RNCM provides skilled nursing care in patients’ homes, oversees care throughout each episode, coordinates multidisciplinary services, and evaluates whether the care provided meets patient needs. The position requires travel to scheduled patient visits in an assigned geographic area, daily attendance at assigned visit locations, participation in on-call requirements and case conferences, and timely completion of clinical documentation.

Requirements

At least one year of experience as an RN in an acute care setting.
Current Registered Nurse license in the state of employment.
Valid driver’s license and auto insurance listing the employee as a driver.
Ability to communicate effectively and create positive impressions with patients, families, physicians, and coworkers.
Ability to remain calm, patient, accommodating, compassionate, and caring when working with patients.
Knowledge of nursing best practices.
Ability to make appropriate nursing judgments and identify situations and handle them with the best possible solution.
Detail-oriented and observant.
Disciplined work ethic with the ability to prioritize and be timely.
Ability to follow directions and work as a team member.

Nice To Haves

Home care experience.

Responsibilities

Oversee the overall care of the patient from the beginning to the end of the episode.
Update physician orders in the patient chart and notify the physician of significant changes in the patient’s condition.
Manage multidisciplinary care as applicable.
Provide skilled nursing care in the patient’s home as ordered by the attending physician.
Observe and monitor patient conditions.
Perform OASIS assessments, develop individualized plans of care, and adjust them as patient needs change.
Administer medications as prescribed by the physician.
Help reduce rehospitalizations by front-loading visits for high-risk patients and teaching patients preventative measures and sound decision-making.
Promote continuity of care through appropriate admissions, transfers, and discharges.
Counsel patients and families about disease or injury processes and how to manage them.
Involve patients and families in developing the plan of care and listen to their concerns.
Oversee and supervise patient care provided by nurse aides and LPNs.
Evaluate treatments and the patient’s medical condition according to the plan of care, and determine whether the level of care meets patient needs.
Communicate supervisory visit results to LPNs and nurse aides.
Complete clinical documentation according to agency protocol and Medicare and federal guidelines, documenting treatment, assessments, and patient education.
Maintain an active RN license and follow the plan of care within the RN scope of practice.
Notify the scheduler of changes outside the normal schedule.
Participate in on-call requirements and case conferences.
Attend in-service trainings and mandatory agency meetings.
Drive to patients’ primary locations for scheduled visits and attend assigned visit locations daily.
Document subsequent, discharge, evaluation/recertification, resumption-of-care, and start-of-care visits within 24 hours of the visits.
Complete and submit all required documentation within company timelines.
Fulfill RN visits in the assigned geographic location according to patient needs and federal and state specifications.
Perform other duties as assigned.