RN Case Manager- Home Health

Carilion Clinic•Hardy, VA

3d•Onsite

About The Position

The RN Case Manager, Home Health and Hospice manages nursing care and provision of individualized care for patients of all ages. Utilizes delegation and critical thinking skills to provide quality service through a team oriented, collaborative approach to patient care. Assesses, plans, implements, and evaluates patient care in order to achieve optimum patient outcomes for patients of all ages as appropriate to service area. Age specific admission and ongoing assessments are completed, documented and used to develop a plan of care. The RN Case Manager, Home Health. Weekends. Company equipment. Mileage reimbursement. Assumes primary accountability for managing nursing care and providing individualized care for patients of all ages. Assesses, plans, implements, and evaluates patient care to achieve optimum outcomes. Completes and documents age-specific admission and ongoing assessments to support the plan of care. Collaborates with the health care team, patient, and family to develop, implement, and revise the interdisciplinary plan of care. Administers and documents treatments and medications using electronic medical record systems. Ensures patient care orders are current, accurate, implemented, and evaluated for effectiveness. Identifies, implements, and documents patient and caregiver education needs. Promotes patient safety, patient-centered care, and positive outcomes during transitions of care. Serves as a patient advocate and supports patients’ psychological, social, and cultural needs. Applies knowledge of growth and development to care for assigned patients. Utilizes clinical expertise in rapidly changing circumstances. Plans strategies to prevent avoidable rehospitalizations, reduce resource use, and improve patient outcomes. Manages resources, establishes priorities, and seeks supervisory direction as needed. Uses problem-solving skills to resolve patient care and staff issues. Participates in performance improvement activities and assigned projects. Assists with providing orientation to new employees and serves as a clinical role model. Manages all aspects of assigned patient care, including case conferences and care coordination. Supervises LPNs and Home Health Aides as required by regulatory guidelines. Maintains accurate and current case management documentation. Ensures visit frequencies reflect provider orders and evidence-based practice. Collaborates with scheduling, billing, and other departments to support care coordination, authorization, and communication of patient financial obligations. Performs skilled visits, including OASIS and recertification visits, as needed. Coordinates required forms, including BIPA, ABN, HHABN, or other forms required by CMS or agency policy. Securely uses electronic devices to access, transfer, and synchronize information to support communication and continuity of care. Coordinates hospice patient and family care in collaboration with the hospice interdisciplinary team, Medical Director, and attending physician. Utilizes understanding of hospice care concepts and issues related to caring for terminally ill patients. Provides competent, compassionate care in a variety of settings. Complies with hospice policies and procedures. Participates in special hospice events, such as grief camps and memorial services.

Requirements

Graduate of accredited Registered Nurse Program.
Currently licensed as Registered Nurse in the state of Virginia or approved compact state.
Must have valid driver’s license, automobile insurance, and personal vehicle for making home visits.
Keyboarding skills required for automated computer systems, including electronic medical records.
Demonstrates knowledge of the principles of life span growth and development and assesses data reflective of the patient’s status.
Interprets the appropriate information needed to identify each patient’s requirements relative to his or her age specific needs and provides care according to departmental policies and procedures.
Work involves application of advanced knowledge and skills of patient care.
Strong critical thinking skills are necessary and needed to interpret laws and regulations related to CHCS and Carilion Clinic.
Work is performed in a patient care environment and is often fast paced, requiring use of prioritization skills.
Applies knowledge of growth and development to appropriately care for patients served.

Nice To Haves

none

Responsibilities

Assumes primary accountability for managing nursing care and providing individualized care for patients of all ages.
Assesses, plans, implements, and evaluates patient care to achieve optimum outcomes.
Completes and documents age-specific admission and ongoing assessments to support the plan of care.
Collaborates with the health care team, patient, and family to develop, implement, and revise the interdisciplinary plan of care.
Administers and documents treatments and medications using electronic medical record systems.
Ensures patient care orders are current, accurate, implemented, and evaluated for effectiveness.
Identifies, implements, and documents patient and caregiver education needs.
Promotes patient safety, patient-centered care, and positive outcomes during transitions of care.
Serves as a patient advocate and supports patients’ psychological, social, and cultural needs.
Applies knowledge of growth and development to care for assigned patients.
Utilizes clinical expertise in rapidly changing circumstances.
Plans strategies to prevent avoidable rehospitalizations, reduce resource use, and improve patient outcomes.
Manages resources, establishes priorities, and seeks supervisory direction as needed.
Uses problem-solving skills to resolve patient care and staff issues.
Participates in performance improvement activities and assigned projects.
Assists with providing orientation to new employees and serves as a clinical role model.
Manages all aspects of assigned patient care, including case conferences and care coordination.
Supervises LPNs and Home Health Aides as required by regulatory guidelines.
Maintains accurate and current case management documentation.
Ensures visit frequencies reflect provider orders and evidence-based practice.
Collaborates with scheduling, billing, and other departments to support care coordination, authorization, and communication of patient financial obligations.
Performs skilled visits, including OASIS and recertification visits, as needed.
Coordinates required forms, including BIPA, ABN, HHABN, or other forms required by CMS or agency policy.
Securely uses electronic devices to access, transfer, and synchronize information to support communication and continuity of care.
Coordinates hospice patient and family care in collaboration with the hospice interdisciplinary team, Medical Director, and attending physician.
Utilizes understanding of hospice care concepts and issues related to caring for terminally ill patients.
Provides competent, compassionate care in a variety of settings.
Complies with hospice policies and procedures.
Participates in special hospice events, such as grief camps and memorial services.