This position assumes responsibility for caseloads consisting of patients in specialty areas. The Home Health RN Case Manager conducts initial assessments to obtain thorough physical, social, and environmental data. They establish the plan of care in accordance with physician orders and patient needs, provide direct patient care, and adjust nursing care processes as needed. The role involves identifying problems, modifying nursing care plans, and evaluating outcomes within an appropriate timeframe. Additionally, the RN Case Manager advises and consults with family and other personnel, provides ongoing assessment of patient response to treatments and teaching, and applies interventions as appropriate. They update and revise the plan of care as indicated, and complete documentation including visit assessment, OASIS, 485, and verbal orders accurately and promptly within standards. Communication with physicians is key 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. The role also facilitates the discharge planning process according to standards and utilizes resources to assure continuity of care after discharge, participating in developing the discharge plan with the patient/family, physician, social worker, and other staff members as appropriate. Participation in chart audits and continuous quality improvement activities is expected, as is identifying, developing, and participating in process improvement opportunities that will enhance the quality of services provided. The RN Case Manager maintains and updates accurate clinical and patient records according to agency, state, and federal guidelines. They must demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served, including principles of growth and development over the life span and the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to their age-specific needs and provide the care needed. Age-specific information is developed further in the departmental job standards.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree