RN Case Manager- Home Health

Carilion Clinic•Lexington, VA

7d•Remote

About The Position

The Home Health and Hospice RN Case Manager assesses, plans, implements, and evaluates patient care in order to achieve optimum patient outcomes for patients of all ages as appropriate to service area. Understands Hospice concept of care and the complex issues related to caring for the terminally ill. Provides competent, compassionate care in a variety of settings. Age specific admission and ongoing assessments are completed, documented and used to develop a plan of care. Collaborates with other members of the health care team/patient/family to develop, implement, and evaluate an age-specific interdisciplinary plan of care. Revises plan according to changes in patient status. Administer and document treatments and medications for patients utilizing automated computer systems, including electronic medical records. Ensures patient care orders are current, accurate, implemented, and evaluated for effectiveness per provider order. Identifies patient/family (caregiver) educational needs, incorporates education into the plan of care, and documents. Contributes to Carilion Clinic’s performance improvement activities. Advocates for patient, protector of patient’s rights, and provider of psychological/social/cultural support. Plans, coordinates, and provides clinical care in a way that promotes positive patient outcomes, promotes safety during vulnerable periods of transition, and upholds a culture of patient centered care. Exhibits clinical expertise in rapidly changing circumstances. Plans strategies to prevent avoidable re-hospitalizations, reduce length of stay, turnaround time, resource consumption and improve patient outcomes. Seeks direction from supervisor as needed in order to affect the best possible outcome for patients served. Manages resources, establishes priorities, and modifies environment to meet patient care needs. Completes manager/director predetermined projects within specified time frame and according to pre-established guidelines. Facilitates resolutions for patient and work situations. May provide orientation to new employees. May supervise LPN as required per regulatory guidelines. LPN supervision will require additional caseload numbers for RN/LPN team. Keeps case management worksheet up to date. Manage case conferences on assigned patients. May supervise Home Health Aides and evaluations. Ensures visit frequencies reflects orders and are appropriate with evidence-based practice. Collaborates with centralized scheduling to ensure appropriate adjustments to visit frequencies are made as needed. Collaborates with billing to ensure pre-authorization is appropriately secured and patient financial obligations are communicated. Performs skilled visits including OASIS visits as needed. “Case Manager” preferably performs recertification visit. Creates new plan of care 485/486. Coordinates appropriate provision of BIPA and ABN forms or any others as directed by CMS or agency policy. Utilizes Mifi device to access information promoting quality of care and continuity. Mifi is also to be utilized to frequently transfer device to promote hand-off of communication.

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

Assesses, plans, implements, and evaluates patient care in order to achieve optimum patient outcomes for patients of all ages as appropriate to service area.
Understands Hospice concept of care and the complex issues related to caring for the terminally ill.
Provides competent, compassionate care in a variety of settings.
Completes age-specific admission and ongoing assessments, documents them, and uses them to develop a plan of care.
Collaborates with other members of the health care team/patient/family to develop, implement, and evaluate an age-specific interdisciplinary plan of care.
Revises plan according to changes in patient status.
Administers and documents treatments and medications for patients utilizing automated computer systems, including electronic medical records.
Ensures patient care orders are current, accurate, implemented, and evaluated for effectiveness per provider order.
Identifies patient/family (caregiver) educational needs, incorporates education into the plan of care, and documents.
Contributes to Carilion Clinic’s performance improvement activities.
Advocates for patient, protector of patient’s rights, and provider of psychological/social/cultural support.
Plans, coordinates, and provides clinical care in a way that promotes positive patient outcomes, promotes safety during vulnerable periods of transition, and upholds a culture of patient centered care.
Exhibits clinical expertise in rapidly changing circumstances.
Plans strategies to prevent avoidable re-hospitalizations, reduce length of stay, turnaround time, resource consumption and improve patient outcomes.
Seeks direction from supervisor as needed in order to affect the best possible outcome for patients served.
Manages resources, establishes priorities, and modifies environment to meet patient care needs.
Completes manager/director predetermined projects within specified time frame and according to pre-established guidelines.
Facilitates resolutions for patient and work situations.
May provide orientation to new employees.
May supervise LPN as required per regulatory guidelines.
Keeps case management worksheet up to date.
Manages case conferences on assigned patients.
May supervise Home Health Aides and evaluations.
Ensures visit frequencies reflect orders and are appropriate with evidence-based practice.
Collaborates with centralized scheduling to ensure appropriate adjustments to visit frequencies are made as needed.
Collaborates with billing to ensure pre-authorization is appropriately secured and patient financial obligations are communicated.
Performs skilled visits including OASIS visits as needed.
Performs recertification visit.
Creates new plan of care 485/486.
Coordinates appropriate provision of BIPA and ABN forms or any others as directed by CMS or agency policy.
Utilizes Mifi device to access information promoting quality of care and continuity.
Utilizes Mifi device to frequently transfer device to promote hand-off of communication.