Home Health RN Case Manager

North Kansas City Hospital•North Kansas City, MO

About The Position

The Registered Nurse Case Manager (RNCM) is accountable for assessing patient conditions and leading the development and implementation of plans of care. The RNCM provides case management and clinical care, coordinates the disciplines involved in delivering quality, cost-effective, billable care, and supervises care under physician direction. The role includes educating patients and family members, safeguarding patient safety, completing accurate documentation, complying with applicable legal requirements, and performing duties within the state-defined scope of practice. The RNCM provides skilled nursing care in patients’ homes and oversees care throughout each episode, including assessments, treatment, medication administration, patient and family education, and coordination with physicians and other care team members. The position requires travel to scheduled patient locations, participation in on-call requirements and case conferences, and timely completion of clinical documentation.

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, and to work compassionately and caringly with patients.
Knowledge of nursing best practices and ability to make appropriate nursing judgments.
Ability to 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 patients from the beginning to the end of each episode.
Update physician orders in the patient chart and notify the physician of significant changes in a patient’s condition.
Manage multidisciplinary care as applicable.
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 needs change.
Administer medication as prescribed by the physician.
Help reduce re-hospitalizations 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; incorporate them into care-plan development and listen to their concerns.
Oversee and supervise the total care provided by nurse aides and LPNs.
Evaluate treatments and patients’ medical conditions against 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 in accordance with agency protocol and Medicare/Federal guidelines, documenting treatment, assessments, and patient education.
Maintain an active RN license.
Inform 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 daily at assigned visit locations.
Document subsequent, discharge, evaluation/recertification, and resumption-of-care visits within 24 hours; document start-of-care visits within 24 hours.
Complete and submit required documentation within company deadlines.
Follow the plan of care within the Registered Nurse scope of practice.
Fulfill RN visits in the assigned geographic location according to patient needs and federal and state specifications.
Perform other duties as assigned.