Registered Nurse, RN- Home Health, Case Manager- Sign on Bonus Eligible!

Tufts Medicine

7d•Remote

About The Position

We are seeking an experienced and compassionate Registered Nurse Case Manager to join our home health team. This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Home Care Nurse duties: Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient’s plan of care as directed. Key responsibilities include conducting comprehensive assessments, developing and overseeing individualized care plans, coordinating with physicians and interdisciplinary team members, monitoring patient progress, and adjusting care plans to achieve optimal outcomes. The RN Case Manager serves as the primary point of contact for patients and families, providing education, support, and advocacy throughout the episode of care. The ideal candidate demonstrates strong clinical expertise, exceptional organizational and communication skills, and the ability to manage a diverse caseload independently while maintaining compliance with regulatory and documentation standards. As a key member of the health care team, this position must interact courteously and effectively with patients and their families as well as with co-workers from all Agency departments, community resources, and with patients' physicians in order to facilitate safe and efficient patient care while maintaining their own safety in the home and the community at large.

Requirements

Massachusetts/New Hampshire RN Licensure.
Valid state issued Driver’s License.
One (1) year of acute medical/surgical nursing experience.
Cardiopulmonary Resuscitation (CPR) Certification.

Responsibilities

Assesses patients' physical, psychosocial needs in a sensitive, caring manner following established Standards of Nursing Practice and VNA procedures.
Assesses patient/family learning needs, style and limitations and adjusts for delivery of information.
Establishes realistic goals and develops plans of treatment in cooperation with the patient, family and members of the health care team.
Collaborates with patient /family and other health care providers and/or community resources with planning of care and discharge.
Completes physicians' orders, levels of care, and OASIS on all patients assigned, in accordance with patient care policies.
Reconciles medications with patient and physician consistently.
Effectively manages assigned caseload, within the team model of care delivery.
Establishes a daily work plan based upon patient/family priorities of service and total area needs.
Promptly triages patient visits, messages, and phone calls according to priority and urgency.
Demonstrates excellent physical assessment and care planning skills.
Demonstrates current knowledge of pharmacology and medication administration and reconciliation.
Demonstrates ability to cope with patient/family emotional stress and provide appropriate supportive care.
Coordinates care and discharge planning with other team members during case conferences.
Acquires and maintains an expert working knowledge of all third part payers and regulatory bodies and agency policies on issues related to documentation and care provided.
Communicates and collaborates with all disciplines in the home care setting on a regular basis or immediately if there are any critical needs or crisis interventions needed.