Home Health Registered Nurse, RN, Case Manager

Tufts Medicine•Lowell, MA

2d•$84,300 - $107,481•Remote

About The Position

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Home Care Nurse duties: Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed. Provides professional nursing care to patients. Requires a nursing license. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs. The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects / processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems. Job Overview Utilizing the nursing process, the Home Health Registered Nurse will manage and deliver comprehensive home health services, including assessments, interventions, and supportive care to clients within their place of residence. Depending on the circumstances, duties may also include telephone triage, problem solving, patient/caregiver advocacy and support, with emphasis of avoiding hospitalization. As a key member of the health care team, this position must interact courteously and effectively with patients and their families as well as with co-workers from all Agency departments, community resources, and with patients' physicians in order to facilitate safe and efficient patient care while maintaining their own safety in the home and the community at large.

Requirements

Massachusetts RN Licensure and NH Licensure.
Valid state issued Driver’s License.
One (1) year of acute medical/surgical nursing experience.
Basic Life Support Certification.
Demonstrates knowledge and skills necessary to provide care appropriate to the age of the patients served.
Demonstrates competence in Home Health and Hospice standards of care, symptom management, psychosocial, and spiritual aspects of care.
Excellent interpersonal skills with the ability to communicate, read, and write in English.
Ability to function well, effectively manage time, and prioritize busy schedules.
Good organizational skills.
Ability to function effectively, autonomously, and independently in a home care setting.
Ability to function effectively and autonomously in a home care setting.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Specialty nursing certifications.
Three (3) years of acute nursing including medical/surgical, oncology, hospice, or home health.
Experience with IV and complex wound care.

Responsibilities

Assesses patients' physical, psychosocial needs in a sensitive, caring manner following established Standards of Nursing Practice and Agency policies and procedures. Provides ongoing interdisciplinary assessment of the patient.
Assesses patient/family learning needs, style and limitations and makes adjustments for delivery of information.
Recognizes/identifies patients/caregivers’ cultural beliefs re: death and dying and is sensitive to those beliefs.
Establishes realistic goals and develops plan of treatment in cooperation with the patient, family and members of the health care team.
Identifies abuse and/or neglect and identifies reporting mechanism per policy.
Adapts to new and unusual situations without affecting work performance negatively. Utilizes Security when and if needed for any potential unsafe situations.
Collaborates with patient /family and other health care providers and/or community resources with planning of care and discharge.
Continuously assesses/evaluates patient and family progress and goal achievement, keeping Clinical Manager advised and justifying continuation and/or termination of services.
Documents patient data, activities, and communications in patient record using computer system in a timely, organized, concise manner to ensure compliance with legal, certification, third party payor guidelines and Agency policies.
Completes physicians' orders, levels of care, and OASIS on all patients assigned, in accordance with patient care policies. Reconciles medications with patient and physician consistently.
Demonstrates and practices according to safety guidelines and procedures including general ergonomics, fire, and personal safety. Utilizes proper body mechanics and patient material handling.
Demonstrates an awareness of safety and security issues by responding appropriately to emergency situations and following established procedures and protocols utilizing stabilizing techniques.
Demonstrates ability to cope with patient/family emotional stress and provide appropriate supportive care.
Effectively manages assigned caseload, within the team model of care delivery. Establishes a daily work plan based upon patient/family priorities of service and total area needs. Promptly triages patient visits, messages, and phone calls according to priority and urgency.
Provides nursing coverage on a rotating basis for evenings, nights, weekends and Holidays.
Demonstrates excellent physical assessment and care planning skills. Demonstrates current knowledge of pharmacology and medication administration and reconciliation.
Coordinates care and discharge planning with other team members during case conferences.
Acquires and maintains an expert working knowledge of all third part payers and regulatory bodies and agency policies on issues related to documentation and care provided.
Communicates and collaborates with all disciplines in the home care setting on a regular basis or immediately if there are any critical needs or crisis interventions needed.