Registered Nurse, Case Manager

Residential Home Health and Residential Hospice•Mifflinburg, PA

1d•Onsite

About The Position

This role involves managing home health referrals, performing patient assessments, developing care plans, and coordinating with various healthcare disciplines and family members. The Registered Nurse Case Manager is responsible for ensuring continuity of care, documenting patient progress, and adhering to agency policies and procedures. The position also includes on-call duties and participation in quality assurance initiatives.

Requirements

Must be able to meet the physical demands of providing nursing care, ambulating patients, transferring patients, assisting with exercises, etc.
Must be able to transfer patients as needed according to proper techniques of body mechanics to promote patient and staff safety.
Must be able to use good and sound clinical judgment.
Must be able to document accurately and appropriately.
Must follow up as needed and appropriately with doctor’s office, clinical and management staff pertaining to any concerns regarding patient care.
Must hold, in good standing, a license as a Registered Nurse, issued by the state in which you work.
Must be empathetic, non-judgmental, tactful, responsible, and organized.
Must understand the team approach and be a supportive team member.
Successfully complete a drug screen prior to employment.
Confirm legal authorization to work in the United States.

Nice To Haves

Current CPR certification preferred.
Current TB screen preferred.
A minimum of one (1) year of experience working as a Registered Nurse including some medical/surgical experience and/or an acute care or home care setting is preferred.
Associate Degree from an accredited School of Nursing or higher preferred.

Responsibilities

Review home health referrals, updating and communicating any changes to other disciplines and the customer service center.
Perform assessments within 24-48 hours of receiving a referral.
Complete all documentation and forward to the office promptly within 24 hours of completion of in-home visit.
Develop rapport with the client and family, ensuring privacy and confidentiality while obtaining accurate client history.
Complete a physical assessment and communicate the findings and plan of care to the physician.
Initiate evaluations to other disciplines (PT, OT, SLP, LPN, MHRN, MSW, RD, HHA) or support services when indicated.
Conduct Home health aide supervisory duties as required by internal policy.
Enter insurance authorization requests within 24 hours of initial evaluation and continue to enter additional requests at the end of each authorization period.
Organize daily assignments, setting priorities based on individual and overall needs of the clients while traveling to each home as scheduled.
Ensure clients have prescribed medications and/or treatment supplies, updating files as changes occur.
Identify appropriate actions that will provide for continuity of care, an individualized teaching plan, and the involvement of the individual and family/caregiver whenever possible.
Formulate a plan of care to achieve expected outcomes through short and long-term goals that are realistic and feasible in terms of resources, time, material, people, and cultural relevancy. Revise the plan of care in response to changes in the individual's status or to adjust to the individual's response to care, and communicate and update with all disciplines, including PPL.
Coordinate discharge planning with direct involvement of client, family/caregiver.
Document any communication and/or orders from the physician.
Attend PCH/ALF case conferences as scheduled, providing weekly client reports to the team and providing PCH/ALF monthly educational in-services as requested by the facility.
Maintain a high level of competency, growth, and development, including ensuring license, CPR, TB testing, etc., are current and in good standing at all times.
Attend nursing staff meetings, quarterly educational in-services, and yearly competency day.
Perform on-call duties per agency requirements/assignment for non-business hours. Position may require after-hours patient visits to achieve positive patient outcomes.
Follow agency policies and procedures as per the Policy and Procedures of the company.
Adhere/assist with company outcome goals as indicated by QI/home health compare tracking.
Follow guidelines as indicated in the employee handbook.
Participate in QA/OBQI initiatives with problem-solving via action items.
Coordinate with Corridor to manage alerts and change requests.
Perform other duties as assigned by management.