The Home Health RN Case Manager assumes responsibility for caseloads consisting of patients in specialty areas. This role conducts initial assessments to obtain thorough physical, social, and environmental data, and establishes the plan of care in accordance with physician orders and patient needs. The RN provides direct patient care, adjusts nursing care processes as needed, and identifies problems, modifies the nursing care plan, and evaluates outcomes within an appropriate time frame. They advise and consult with family and other personnel as appropriate, and provide ongoing assessment of patient response to treatments and teaching, applying interventions as appropriate and updating the plan of care as indicated. This role also involves completing documentation accurately and promptly, communicating with physicians to confirm and update patients' plan of care, providing status updates, and ensuring ongoing communication with the physician and other members of the health care team. Additionally, the RN facilitates the discharge planning process according to standards, utilizes resources to assure continuity of care after discharge, and participates in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate. The position also requires participation in chart audits and continuous quality improvement activities, identifying, developing, and participating in process improvement opportunities. The RN must maintain and update accurate clinical and patient records according to agency, state, and federal guidelines and demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served, including understanding the principles of growth and development over the life span and assessing data reflective of the patient's status.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree