Home Health RN Case Manager

Alternate Solutions Health Network•North Kansas City, MO

About The Position

The Registered Nurse Case Manager (RNCM) is accountable for leading the assessment of patient conditions and the development and oversight of plans of care. The role provides case management and skilled nursing care, coordinates and supervises the disciplines involved in delivering quality, cost-effective, billable care under physician direction, and helps ensure patient safety. The RN educates patients and families, completes accurate clinical documentation, complies with applicable legal requirements, and works within the state-defined scope of practice. The RNCM oversees patient care throughout the episode, coordinates with physicians and other care team members, and evaluates whether the level of care and treatments meet the patient's needs. The position includes home visits within an assigned geographic area, participation in on-call requirements and case conferences, and attendance at trainings and mandatory agency meetings. Documentation for visits must be completed within 24 hours, with all other required records submitted according to company requirements.

Requirements

At least one year of RN experience in an acute care setting.
Registered Nurse with a current 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.
Compassionate and caring approach to working with patients.
Knowledge of nursing best practices.
Ability to make appropriate nursing judgments and identify situations and respond with effective solutions.
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 patient's 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.
Manage multidisciplinary care as applicable and coordinate care with the involved disciplines.
Provide skilled nursing care in patients' homes as ordered by the attending physician.
Observe and monitor patient conditions.
Perform OASIS assessments, develop individualized plans of care, and adjust plans 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 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 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 against 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 in accordance with agency protocols and Medicare and federal guidelines, documenting treatments, assessments, and patient education.
Maintain an active RN license and follow the plan of care within the Registered Nurse scope of practice.
Notify the scheduler of changes outside the normal schedule.
Participate in on-call requirements and case conferences, and attend in-service trainings and mandatory agency meetings.
Drive to scheduled patient visit locations and fulfill RN visits in the assigned geographic area according to patient needs and federal and state specifications.
Document start-of-care, subsequent, discharge, evaluation, recertification, and resumption-of-care visits within 24 hours, and submit all required documentation within company deadlines.
Perform other duties as assigned.