RN Case Manager- Home Heath

Carilion Medical Center•Lexington, KY

1d•Onsite

About The Position

Make the most of your clinical skills at an organization that has earned numerous awards for clinical excellence. Based in Roanoke, Virginia, our community-based healthcare network encompasses seven hospitals including a U.S. News & World Report Top 10 Hospital and two Magnet®-designated hospitals multi-specialty physician practices, and affiliations with prestigious academic medical institutions. Based in Roanoke, Virginia, we’re a regional leader that inspires optimal health through compassionate care, medical education and research, and neighborhood outreach. Realize the advantages of joining and a regional healthcare leader, including supportive leadership, inter-professional teams, state-of-the-art technology innovative learning and training, and advancement potential. Below are our core values that we strive to embody and expect of all our team members: Collaboration: Working together with purpose to achieve shared goals. Commitment: Unwavering in our quest for exceptional quality and service. Compassion: Putting heart into everything we do. Courage: Doing what's right for our patients without question. Curiosity: Fostering creativity and innovation in our pursuit of excellence. The Home Health and Hospice RN Case Manager assesses, plans, implements, and evaluates patient care in order to achieve optimum patient outcomes for patients as appropriate to service area. Age specific admission and ongoing assessments are completed, documented and used to develop a plan of care. nursing care and provision of individualized care for patients. Utilizes delegation and critical thinking skills to provide quality service through a team oriented, collaborative approach to patient care.

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.

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.
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.