RN Case Manager Home Health

Wellstar Health System

9h•Onsite

About The Position

The RN Case Manager is responsible for providing and supervising primary care to approximately 25-35 patients in their home setting. This includes age-appropriate interventions that meet physical, emotional, developmental, psychosocial, and educational needs. The RN Case Manager is responsible for the coordination of all disciplines throughout the episode of care. The RN Case Manager communicates with all team members including RNs, LPNs, Therapists, Social Workers, Home Health Aides, the Physician, patient, family, and other internal or external individuals to ensure that the patient's plan of care is appropriately developed, implemented, and that goals are met. The RN Case Manager supervises the LPNs and Home Health Aides throughout the patient plan of care. The RN Case Manager participates with leadership to develop and implement processes to continue improvement with patient and agency outcomes.

Requirements

Minimum 1 year of Medical/Surgical Nursing Required
RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
GADL - Georgia Driver's License or VSDL - Valid State Driver's License
PVI - Private Vehicle insurance
Strong critical care assessment and clinical skills required.
Positive leadership, problem solving skills, strong organizational and time management skills.
Strong communication (written and verbal) skills.
Ability to write and follow directions to patients homes.
Use of Windows based computer, utilizing home health patient software, email, internet, computer based learning modules, etc.
Good understanding of home health operations, reimbursement, law and regulatory processes.

Nice To Haves

Home Health, and ICU experience Preferred
OASIS knowledge preferred.

Responsibilities

Assesses, coordinates with other disciplines and manages patients total needs, following physicians orders, using the nursing process
Develops patients plan of care coordinating with other disciplines
Manages patient from admission through recerts to discharge and appropriately scheduling visits per physicians order: adjust frequency as needed, based on patient clinical status and MD order
Performs routine and complex nursing procedures to meet the need of the patient
Revises the plan of care based on patient need within physician orders, coordinating with other disciplines to ensure goals are met to achieve positive outcomes prior to discharge
Supervises LPNs and Home Health Aides throughout the continuum of care.
Develops and supervises the care plan provided to the Home Health Aides
Reviews Plan of Care for patients with the Manager Home Health and other team members and support services
Maintains communication with physician reporting any changes that may affect the patients recovery
Provides patient/caregiver education to develop and encourage self care to achieve positive outcomes
Utilizes both verbal and written tools to facilitate learning and promotion of independence during recovery
Be aware and report concerns to authorities or agency leadership on any issues that affect patient or staff safety
Communicates patient status changes and lab results to the physician as appropriate.
Participates in care team conferences
Responsible for checking voice mail box and staff messaging a minimum of once daily
Demonstrates knowledge and appropriate application of CMS/State, and Joint Commission regulatory guidelines.
Responsible for accurate completion of required OASIS and visit documentation in the patients EMR
Completes all documentation within established timeframes
Participates in the orientation and education of new employees as appropriate
Responsible for attending continuing education and in-services as directed and needed
Responsible to remain current in clinical knowledge for the care of the home health patient
Receives training, supervision or direction from leadership as needed
Participates in department performance improvement activities (i.e. chart review, committees, etc.).
Participates in system-wide committees as requested.
Identifies methods for improving department performance/care.
Assists in implementing performance improvement opportunities
Meets established productivity standards
Weekend and call rotation as required
Perform other duties as assigned by Home Health Leadership
Performs other duties as assigned
Complies with all WellStar Health System policies, standards of work, and code of conduct.