Home Health RN Case Manager (PRN)
About The Position
The Home Health RN Case Manager provides nursing care for clients of all ages in their place of residence. This role involves coordinating care with the interdisciplinary team, patient/family, and referring agency, and assuming responsibility for care coordination. The primary functions include conducting initial and ongoing comprehensive assessments of the patient's physical, functional, psychosocial, and environmental needs related to their disease, implementing and revising individualized care plans, and educating patients and families about disease processes, self-care, end-of-life care, and nutrition. The role also involves initiating preventive and rehabilitative nursing procedures, preparing clinical notes, coordinating patient and family services, communicating changes in patient needs to the physician and other personnel, determining the scope and frequency of services, assessing caregiver abilities, and evaluating personal support needs.
Requirements
- Ability to work in patients’ homes in various conditions; possible exposure to blood and bodily fluids and infectious diseases.
- Must be able to work on a flexible schedule.
- Must have the means to travel locally.
- Some exposure to unpleasant weather.
- Associate, or Baccalaureate degree in nursing
- Current, unencumbered license to practice Registered Nursing in Texas
- Current CPR certification
- Reliable transportation
Responsibilities
- Provide nursing care for clients of all ages in their place of residence.
- Coordinate care with the interdisciplinary team, patient/family, and referring agency.
- Assume responsibility for coordination of care.
- Conduct initial and ongoing comprehensive assessments of the impact of the terminal disease on the patient's physical, functional, psychosocial, and environmental needs and ADLs.
- Implement the individualized POC and recommend revisions to the plan as necessary.
- Consult with and educate the patient and family regarding the disease process, self-care techniques, end-of-life care, nutrition, and dietary needs.
- Provide training to other staff as needed.
- Initiate appropriate preventive and rehabilitative nursing procedures.
- Prepare clinical and progress notes that demonstrate progress toward established goals.
- Coordinate all patient and family services and prioritization of needs with the members of the IDT.
- Inform physician and other personnel of changes in the patient’s needs and outcomes of the intervention, while evaluating patient/family response to care.
- Determine scope and frequency of services needed based on acuity and patient/family needs.
- Assess the ability of the caregiver to meet the patient’s immediate needs upon admission and throughout care.
- Evaluate own needs for support and using identified systems to meet the need.
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What This Job Offers
Career Level
Mid Level
Education Level
Associate degree
