The PM Home Health Registered Nurse Case Manager will assume responsibility for caseloads consisting of patients in specialty areas. This role involves conducting initial assessments to obtain thorough physical, social, and environmental data, and establishing a plan of care in accordance with physician orders and patient needs. The nurse will provide direct patient care, adjust nursing care processes as needed, identify problems, modify the nursing care plan, and evaluate outcomes. They will also advise and consult with family and other personnel, provide ongoing assessment of patient response to treatments and teaching, and update the plan of care as indicated. Documentation, including visit assessment, OASIS, 485, and verbal orders, must be completed accurately and promptly. Communication with physicians is crucial to confirm and update patients' plan of care, and to ensure ongoing communication with the healthcare team. The role also facilitates the discharge planning process according to standards, utilizes resources to assure continuity of care after discharge, and participates in chart audits and continuous quality improvement activities. Maintaining accurate clinical and patient records according to agency, state, and federal guidelines is essential. The nurse must 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 patient status to identify age-specific needs.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree