Home Health RN Case Manager

CenterWell•Overland Park, KS

About The Position

The Home Health RN Case Manager provides admission, case management, follow-up skilled nursing visits, and ongoing care for home health patients. The role develops and manages patient treatment plans in consultation with physicians and under the supervision of the Clinical Manager, providing hands-on care, evaluation, patient and family teaching, and plan revisions based on ongoing assessments and applicable policies and regulations. The Case Manager coordinates care with healthcare personnel and external providers, reports patient condition and progress to physicians and the Clinical Manager, and helps patients and families achieve optimal resolution of care needs. The role also oversees Home Health Aides, Certified Home Health Aides, and Personal Care Workers, including providing written care instructions and monitoring documentation. Responsibilities include discharge planning and clinical documentation, maintaining patient records, preparing visit and shift reports, and communicating with other healthcare disciplines.

Requirements

Diploma, Associate degree, or Bachelor's degree in Nursing.
At least one year of nursing experience.
Strong med-surg, ICU, ER, or acute care experience.
Current and unrestricted Registered Nurse licensure.
Current CPR certification.
Strong organizational and communication skills.
Valid driver's license, auto insurance, and reliable transportation.

Nice To Haves

Home Health experience.

Responsibilities

Provide admission, case management, and follow-up skilled nursing visits for home health patients.
Administer ongoing patient care and case management, with follow-up as directed by the Clinical Manager.
Confer with physicians to develop initial treatment plans based on physician orders and initial patient assessments.
Provide hands-on care, evaluate care plans, and teach patients in accordance with physician orders and under Clinical Manager supervision.
Revise care plans in consultation with physicians based on ongoing assessments and applicable policies and regulations.
Coordinate appropriate care with healthcare personnel, including Physical Therapists, Occupational Therapists, Home Health Aides, and external providers.
Continuously report patient care, condition, and progress to the patient's physician and Clinical Manager.
Implement patient care plans in conjunction with patients and families to help resolve their needs and problems.
Coordinate, oversee, and supervise Home Health Aides, Certified Home Health Aides, and Personal Care Workers; provide written personal care instructions and care plans reflecting the current plan of care.
Monitor completion of documentation by home health aides and personal care workers.
Discharge patients after consultation with the physician and Clinical Manager, completing required clinical documentation.
Prepare medical documentation, including case conferences, patient contacts, medication order changes, recertifications, progress updates, and care plan changes.
Prepare visit and shift reports, update and summarize patient records, and confer with other healthcare disciplines to provide optimum patient care.