Registered Nurse (RN) Case Manager - Home Health

ATEX Healthcare Home Health•Corpus Christi, TX

About The Position

Plans, organizes, and directs home care services, using nursing experience and community health education to meet the needs of individuals and families in their homes and communities. Ensures staff and support resources are appropriately utilized and maintains interdisciplinary teamwork through delegation for Home Health and Hospice. The role includes patient assessment and care planning, coordinating care for an assigned caseload when designated as case manager, communicating with physicians and community health professionals, and directing and evaluating aide and LPN/LVN services. The position is full-time and located in Corpus Christi, Texas.

Requirements

Current and valid nursing licensure in the state of employment.
One to two years of recent acute care experience in an institutional setting.
Current and valid CPR certification.
Licensed driver with an automobile insured in accordance with state or company requirements and in good working order.
Capable of performing the job functions with or without accommodations.
Complies with acceptable professional standards and practices.
Demonstrates good communication and management skills.
Demonstrates autonomy, organization, assertiveness, flexibility, and cooperation in performing job responsibilities.

Nice To Haves

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

Responsibilities

Complete initial and ongoing OASIS assessments of patients and families to determine home care needs, or comprehensive assessments of the impact 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 to ensure quality and continuity; recommend and make revisions as patient status and needs change.
Use health assessment data to determine nursing diagnoses and establish goals and therapeutic, preventive, and rehabilitative nursing actions.
Include patients and families in care planning and counsel them on nursing and related needs.
Initiate appropriate preventive and rehabilitative nursing procedures and administer prescribed medications and treatments.
When applicable, consult with and educate patients and families about disease processes, self-care, end-of-life care, nutrition, and dietary needs.
Prioritize needs with members of the interdisciplinary group/team and provide training to other staff as needed.
Provide health care instructions appropriate to assessments and plans of care; determine service scope and frequency based on acuity and patient and family needs.
Identify discharge-planning needs and implement them before patient discharge.
Act as case manager when assigned by the Clinical Supervisor and coordinate care for the assigned caseload.
Prepare clinical notes and update the primary physician when necessary and at least every 60 days.
Communicate patient needs and changes in condition to physicians, obtain or receive physician orders as required, and inform physicians and other personnel of changes and intervention outcomes.
Coordinate care plans with community health-related personnel.
Participate in on-call duties as defined by the on-call policy.
Ensure arrangements are available for equipment and other necessary items and services.
Provide clinical direction to aides and LPN/LVNs to ensure quality and continuity of services.
Instruct, supervise, and evaluate Home Health and/or Hospice aide care every 14 days.
Adhere to company policies and procedures and perform other duties as assigned.