RN Case Manager- Home Health

Carilion Clinic•Radford, VA

10d•$34 - $50•Onsite

About The Position

The RN Case Manager provides and manages individualized nursing care for patients of all ages in a home health setting in the NRV region. The role uses delegation, clinical expertise, critical thinking, and a collaborative, team-oriented approach to support quality care and optimum patient outcomes. The nurse completes age-specific admission and ongoing assessments; develops, implements, and evaluates plans of care; coordinates care with patients, families, and the interdisciplinary team; and maintains accurate case management documentation. Responsibilities include administering and documenting treatments and medications in electronic medical record systems, ensuring orders are current and effective, educating patients and caregivers, and promoting safety and positive transitions of care. The case manager performs skilled visits, including OASIS and recertification visits, as needed; coordinates case conferences, authorizations, scheduling, billing communication, and required forms; and supervises LPNs and Home Health Aides as required. The role also includes hospice-related coordination and care in collaboration with the hospice interdisciplinary team, Medical Director, and attending physician, as well as participation in hospice events. This is a full-time day-shift position with occasional on-call responsibilities. Company equipment, mileage reimbursement, and sign-on bonus eligibility are noted.

Requirements

Graduate of an accredited Registered Nurse program.
Currently licensed as a Registered Nurse in Virginia or an approved compact state.
Valid driver’s license, automobile insurance, and a personal vehicle for home visits.
Keyboarding skills for automated computer systems, including electronic medical records.
Knowledge of life-span growth and development and the ability to assess patient status and provide age-specific care according to departmental policies and procedures.
Ability to apply advanced patient-care knowledge and skills.
Strong critical-thinking and prioritization skills, including the ability to interpret laws and regulations related to CHCS and Carilion Clinic and work in a fast-paced patient-care environment.

Responsibilities

Manage nursing care and provide individualized care for patients of all ages.
Assess, plan, implement, and evaluate patient care to achieve optimum outcomes.
Complete and document age-specific admission and ongoing assessments and use them to develop plans of care.
Collaborate with the health care team, patient, and family to develop, implement, and revise interdisciplinary plans of care.
Administer and document treatments and medications using electronic medical record systems.
Ensure patient care orders are current, accurate, implemented, and evaluated for effectiveness.
Identify, implement, and document patient and caregiver education needs.
Promote patient safety, patient-centered care, and positive outcomes during transitions of care.
Advocate for patients and support their psychological, social, and cultural needs.
Apply knowledge of growth and development to patient care and use clinical expertise in rapidly changing circumstances.
Plan strategies to prevent avoidable rehospitalizations, reduce resource use, and improve patient outcomes.
Manage resources, establish priorities, seek supervisory direction as needed, and resolve patient care and staff issues.
Participate in performance improvement activities and assigned projects.
Assist with orientation of new employees and serve as a clinical role model.
Manage assigned patient care, including case conferences and care coordination.
Supervise LPNs and Home Health Aides as required by regulatory guidelines.
Maintain accurate and current case management documentation and ensure visit frequencies reflect provider orders and evidence-based practice.
Collaborate with scheduling, billing, and other departments regarding care coordination, authorization, and communication of patient financial obligations.
Perform skilled visits, including OASIS and recertification visits, as needed.
Coordinate required forms, including BIPA, ABN, HHABN, and other forms required by CMS or agency policy.
Securely use electronic devices to access, transfer, and synchronize information for communication and continuity of care.
Coordinate hospice patient and family care with the hospice interdisciplinary team, Medical Director, and attending physician.
Apply understanding of hospice care concepts and issues related to caring for terminally ill patients.
Provide competent, compassionate care in a variety of settings and comply with hospice policies and procedures.
Participate in special hospice events, such as grief camps and memorial services.
Participate in occasional on-call coverage.