Home Health Registered Nurse Case Manager

Alternate Solutions Health Network•North Kansas City, MO

About The Position

The Registered Nurse Case Manager (RNCM) is accountable for assessing patient conditions and leading development and oversight of each patient’s plan of care. The RNCM provides case management and skilled nursing care in patients’ homes, coordinating and supervising the disciplines involved in delivering quality, cost-effective, billable care under physician direction. The role includes educating patients and families, promoting patient safety, completing accurate clinical documentation, and complying with applicable legal requirements, Medicare and federal guidelines, and the state-defined scope of practice. The RNCM oversees patient care throughout the episode, communicates with physicians and other care team members, evaluates whether the care provided meets patient needs, and supports continuity of care. The position requires travel to scheduled patient locations in the assigned geographic area, participation in on-call requirements and case conferences, and attendance at required trainings and agency meetings. The employee must meet the described physical and sensory demands, with or without reasonable accommodations.

Requirements

At least one year of RN experience 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, and accommodating.
Compassion and care when working with patients.
Knowledge of nursing best practices.
Ability to make appropriate nursing judgments and identify situations and handle them with an appropriate 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.
Ability to meet the physical and sensory demands described in the job posting, with or without reasonable accommodations, including frequent walking, sitting, and driving; occasional lifting up to 50 pounds with or without assistance; and frequent use of computers or PDAs.

Nice To Haves

Home care experience.

Responsibilities

Oversee the patient’s overall care 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.
Coordinate 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 needs change.
Administer medications as prescribed by the physician.
Help reduce re-hospitalizations by front-loading visits for high-risk patients and teaching patients preventive 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 management, and involve them in developing the plan of care.
Listen to patients and family members.
Oversee and supervise the 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 the patient’s needs.
Communicate supervisory visit results to LPNs and nurse aides.
Complete clinical documentation according to agency protocol and Medicare and federal guidelines, documenting treatments, assessments, and patient education.
Maintain an active RN license.
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 start-of-care, subsequent, discharge, evaluation, recertification, and resumption-of-care visits within 24 hours of the visit.
Submit required documentation within specified company requirements.
Follow the plan of care within the Registered Nurse scope of practice.
Complete RN visits in the assigned geographic area according to patient needs and federal and state specifications.
Perform other duties as assigned.