Fairfax RN (Registered Nurse) Case Manager

Mercy Medical Center Home Health•Fairfax, VA

About The Position

The Registered Nurse Case Manager (RNCM) is accountable for leading patient assessment and care planning, providing case management and skilled nursing care, and coordinating the disciplines involved in delivering quality, cost-effective, billable care. The role provides direct care and supervises care under physician direction, educates patients and family members, promotes patient safety, and maintains accurate documentation in compliance with agency protocols, Medicare and federal guidelines, applicable laws, and the state RN scope of practice. The position serves patients in their homes across the Fairfax territory, including Arlington, Alexandria City, Alexandria, Falls Church, Kingstown, Ft. Belvoir, Lorton, and Mt. Vernon. The stated schedule is Monday through Friday, 8:30 a.m.–5:00 p.m., with on-call requirements. The RN travels to assigned patient locations and participates in required on-call coverage, case conferences, trainings, and agency meetings.

Requirements

At least one year of experience as an RN in an acute care setting.
Current Registered Nurse license in the state of employment.
Valid driver's license and auto insurance listing the employee as a driver.
Ability to communicate effectively and create positive impressions with patients, families, physicians, and coworkers.
Ability to remain calm, patient, and accommodating, and to work compassionately with patients.
Knowledge of nursing best practices and ability to make appropriate nursing judgments.
Ability to identify situations and determine effective solutions.
Detail-oriented and observant.
Disciplined work ethic, with the ability to prioritize and be timely.
Ability to follow directions and work as a team member.

Nice To Haves

Home care experience.

Responsibilities

Oversee the patient's care from the beginning to the end of the episode.
Update physician orders in the patient chart and notify the physician of significant changes in the patient's condition.
Manage multidisciplinary care as applicable.
Provide skilled nursing care in patients' homes as ordered by the attending physician.
Observe and monitor patient conditions.
Perform OASIS assessments, develop individualized plans of care, and adjust plans as needs change.
Administer medication as prescribed by the physician.
Help reduce rehospitalizations by front-loading visits for high-risk patients and teaching patients preventive measures and sound decision-making.
Promote continuity of care through appropriate admissions, transfers, and discharges.
Counsel patients and families about disease or injury processes and management, and involve them in developing the plan of care.
Listen to patients and family members.
Oversee and supervise care provided by nurse aides and LPNs; evaluate treatments and medical conditions against the plan of care and determine whether the level of care meets patient needs.
Communicate supervisory visit results to LPNs and nurse aides.
Complete accurate clinical documentation in accordance with agency protocol and Medicare and federal guidelines, including documentation of treatment, assessments, patient education, and required visit types.
Document start-of-care, subsequent, discharge, evaluation/recertification, and resumption-of-care visits within 24 hours, and submit required documentation within company timelines.
Maintain an active RN license and follow the plan of care within the RN scope of practice.
Communicate schedule changes outside the normal schedule to the scheduler.
Participate in on-call requirements and case conferences, and attend in-service trainings and mandatory agency meetings.
Drive to assigned patient locations and fulfill RN visits in the assigned geographic area according to patient needs and federal and state specifications.
Perform other duties as assigned.