Registered Nurse (RN) Home Care Case Manager

Schuylkill•Allentown, PA

5d•Onsite

About The Position

Imagine a career at one of the nation's most advanced health networks. Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work. LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day. Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network. LV HOME CARE AND HOSPICE REGISTERED NURSE (RN) HOME CARE CASE MANAGER - FULL TIME DAYS Summary Responsible for coordinating and directing the delivery of care for an assigned case load of patients who are receiving services in the home setting in collaboration with the interdisciplinary care team and Home Health Care Navigator. Determines home health as the appropriate level of the care for the patient as well as skilled need for services ordered based on home health Conditions of Participation. Initiates, reviews, evaluates, and revises the established plan of care in collaboration with the physician, interdisciplinary team, and Home Health Care Navigator to for appropriate care plan progression aimed at achieving patient goals, quality metrics, and level of care transition through discharge planning. Performs initial and ongoing assessments and skilled treatments and interventions as ordered by the physician and provides patient/caregiver education aimed at achieving patient goals/outcomes.

Requirements

Specialized Diploma Nursing or Associate’s Degree Nursing
1 year recent experience providing care in a Home Health care setting and demonstrate skills in OASIS data set collection. and 1 year Demonstrated ability to coordinate and manage a patient caseload.
or Less than 1 year with demonstrated capacity to complete necessary essential functions of the position as determined by the leadership team.
Knowledge of patient education techniques and principles
Ability to take initiative and function independently without direct supervision
Ability to actively participate as a member of a care team
Exhibit excellent time management and organizational skills
Ability to manage a caseload of 25+ patients
Ability to travel to patient care assignments
Knowledge of home health Conditions of Participation
Knowledge of and skill in completing OASIS data set collection with a high level of accuracy
American Heart Association Basic Life Support - State of Pennsylvania Upon Hire
RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire
DL - Driver's License_PA - State of Pennsylvania Upon Hire

Nice To Haves

Bachelor’s Degree Nursing
1 year Experience as Home Health Care Admission Nurse or Case manager
AMB-BC- Ambulatory Care Nursing ANCC - State of Pennsylvania within 3 Years

Responsibilities

Coordinates and directs the delivery of care for an assigned case load of patients who are receiving services in the home setting in collaboration with the interdisciplinary care team and Home Health Care Navigator.
Initiates, reviews, evaluates, and revises the established plan of care in collaboration with the physician, interdisciplinary team, and Home Health Care Navigator for appropriate care plan progression aimed at achieving patient goals, quality metrics, and level of care transition through discharge planning.
Works in collaboration with other network entities to ensure appropriate delivery of patient care and care progression. These programs include but are not limited to Wound Center, Remote patient Monitoring, Transition of Care Teams, Case Managment, Care coordinator/navigators, and PCP / Specialist Physician offices.
Responsible for completing the OASIS data collection as per CMS regulation with a high level of accuracy that reflects quality outcomes measures and appropriate financial reimbursement for services.
Formulates an individualized plan of care according to physician orders that incorporates the analysis of assessment data and current scientific findings. Collaborates with the physician and Home Health Care Navigator.
Determines home health as the appropriate level of care for the patient as well as skilled need for services ordered based on home health Conditions of Participation.
Relays significant changes in patient status to the physician and other members of the interdisciplinary care team in a time period consistent with patient needs.
Delivers patient care based on the medical plan of treatment established by the physician and protocols using a patient family centered approach.
Provides educational opportunities for patients, families, and clinical staff focusing on end-of-life issues, palliative care, advance directives, chronic disease management, pain management, symptom control, home care, hospice, and discharge planning.
Promotes patient/caregiver autonomy.
Evaluates effectiveness of teaching and modifies education based on patient needs and goals.