RN Case Manager- Home Health

Carilion Clinic•Lexington, VA

11d•$34 - $50

About The Position

The Home Health RN Case Manager assesses, plans, implements, and evaluates patient care to achieve optimal outcomes for patients of all ages in the service area. The role completes and documents age-specific admission and ongoing assessments and uses them to develop individualized plans of care. The RN provides competent, compassionate care in a variety of settings, including care for patients with complex needs, and collaborates with patients, families, and other healthcare team members to develop, implement, and evaluate interdisciplinary plans of care. The Case Manager coordinates clinical services, evaluates patient status and treatment effectiveness, supports safe transitions, and works to prevent avoidable rehospitalizations. The position may supervise LPNs and Home Health Aides, manage case conferences, perform skilled and OASIS visits, and coordinate scheduling, billing, and required patient forms. The role serves the greater Lexington coverage area and includes company equipment, mileage reimbursement, and sign-on bonus eligibility.

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 making 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.
Advanced patient-care knowledge and skills.
Strong critical-thinking skills, including the ability to interpret laws and regulations related to CHCS and Carilion Clinic.
Ability to prioritize work in a fast-paced patient-care environment.

Responsibilities

Assess, plan, implement, and evaluate patient care to achieve optimal outcomes for patients of all ages.
Complete and document age-specific admission and ongoing assessments and use them to develop individualized plans of care.
Collaborate with patients, families, caregivers, and healthcare team members to create, implement, and evaluate age-specific interdisciplinary plans of care; revise plans as patient status changes.
Administer and document treatments and medications using automated computer systems, including electronic medical records.
Ensure patient care orders are current, accurate, implemented, and evaluated for effectiveness according to provider orders.
Identify patient and caregiver education needs, incorporate education into the plan of care, and document education.
Advocate for patients, protect their rights, and provide psychological, social, and cultural support.
Coordinate and provide clinical care that promotes positive outcomes, safety during transitions, and patient-centered care.
Develop strategies to prevent avoidable rehospitalizations, reduce length of stay and resource consumption, and improve patient outcomes.
Manage resources, establish priorities, and adapt the environment to meet patient care needs.
Seek supervisor guidance as needed and facilitate resolutions for patient and work situations.
Complete assigned manager or director projects within specified time frames and guidelines.
Provide orientation to new employees as needed.
Supervise LPNs as required by regulatory guidelines and supervise Home Health Aides and conduct evaluations as needed.
Keep case management worksheets up to date and manage case conferences for assigned patients.
Ensure visit frequencies reflect orders and evidence-based practice; coordinate adjustments with centralized scheduling.
Collaborate with billing to secure pre-authorization and communicate patient financial obligations.
Perform skilled visits, including OASIS visits, as needed; preferably conduct recertification visits and create new plans of care (485/486).
Coordinate provision of BIPA, ABN, and other forms as directed by CMS or agency policy.
Use a Mifi device to access information, support continuity of care, and transfer information for handoff communication.
Contribute to Carilion Clinic performance improvement activities.