Registered Nurse (RN) Case Manager - Home Health

ATEX Healthcare•Corpus Christi, TX

About The Position

The Registered Nurse Case Manager plans, organizes, and directs home care services, drawing on nursing experience and community health education to plan and coordinate services for individuals and families in their homes and communities. The role ensures that staff and support resources are used appropriately and that interdisciplinary teamwork is maintained through delegation for Home Health and Hospice. When assigned by the Clinical Supervisor, the nurse serves as Case Manager and coordinates care for an assigned caseload.

Requirements

Current, valid nursing licensure in the state of employment.
One to two years of recent acute care experience in an institutional setting.
Current, valid CPR certification.
Licensed driver with an automobile insured according to state or company requirements and in good working order.
Comply with acceptable professional standards and practice.
Demonstrate good communication and management skills.
Demonstrate autonomy, organization, assertiveness, flexibility, and cooperation in performing job responsibilities.
Be capable of performing the position’s job functions with or without accommodations.

Nice To Haves

Bachelor’s degree.
One year of home health and/or hospice care experience.

Responsibilities

Complete initial and ongoing OASIS assessments or comprehensive assessments of the effects of terminal disease on patients’ physical, functional, psychosocial, and environmental needs.
Conduct physical assessments and obtain histories of current and previous illnesses; regularly reevaluate patients’ nursing needs.
Develop, implement, and document plans of care, revising them as patient status and needs change.
Use assessment data to determine nursing diagnoses and establish goals and therapeutic, preventative, and rehabilitative nursing actions.
Include patients and families in care planning and provide counseling and health care instructions appropriate to assessments and plans of care.
Initiate preventative and rehabilitative nursing procedures and administer medications and treatments as prescribed by physicians.
Educate patients and families about disease processes, self-care, end-of-life care, nutrition, and dietary needs, when applicable.
Prioritize needs with members of the IDG/T and train other staff as needed.
Determine the scope and frequency of services based on acuity and patient and family needs.
Identify discharge-planning needs, incorporate them into care plans, and implement them before discharge.
Coordinate care for an assigned caseload when acting as Case Manager.
Prepare clinical notes and update the primary physician when necessary and at least every 60 days.
Communicate with physicians about patient needs and condition changes, obtain or receive physician orders as required, and inform physicians and other personnel about changes and intervention outcomes.
Communicate with community health-related personnel to coordinate care plans.
Participate in on-call duties as defined by the on-call policy.
Ensure arrangements are made for equipment and other necessary items and services.
Provide clinical direction to Aides and LPN/LVNs to support quality and continuity of service.
Instruct, supervise, and evaluate Home Health and/or Hospice aide care every 14 days.
Follow company policies and procedures and perform other duties as assigned.