RN Case Manager

Sequoia Home Health•Milpitas, CA

1d•$60 - $65

About The Position

The ideal RN Case Manager is enthusiastic about delivering superior, patient-centered care and is an excellent communicator with all types of patients. Under the general supervision of the Clinical Supervisor, the case manager assesses, plans, organizes and directs the patient’s plan of care. This person will be responsible for building from the resources of the Agency, to plan and direct services and the interdisciplinary care team to meet the needs of the individual and families within their home and communities.

Requirements

Current CA RN License required
CPR/BLS certification
Current driver’s license, safe driving record, and reliable transportation
Graduate of an accredited school of professional clinical with BSN preferred.
Two plus years of professional clinical experience within the last 5 years. (One year experience waived with proof of completion of DHS approved Program Flexibility from a certified Home Health agency.)
Knowledge of OASIS, CMS 485, Title 22, Medicare Conditions of Participation and The Joint Commission standards
Excellent communications, both written and verbal, organizational, presentation and facilitation skills
Ability to speak, read, and write English.
Self-directed with the ability to work with little supervision.
Excellent observation skills
Flexible and cooperative in fulfilling role obligation.
Ability to maintain confidentiality in all aspects of the job.
Proficiency in Microsoft Office
Schedule flexibility necessary to meet the needs of patients as well as the leadership team.

Nice To Haves

Bilingual (English/Spanish) a plus

Responsibilities

Review all available and pertinent patient medical records and requests for additional records, as necessary.
Provide professional clinical care by utilizing all elements of the clinical process.
Develop a Plan of Care (POC) that establishes goals, based on clinical diagnosis, and incorporates clinical interventions.
Coordinate with the physician, patient/family, and care team in developing, writing, and initiating the plan of care.
Regularly re-evaluate patient and family/caregiver needs.
Revise the plan of care, as necessary.
Initiate the plan of care and makes necessary revisions as patient status and needs change.
Use health assessment data to determine clinical diagnosis and treatment plan.
Include the patient and the family in the planning process.
Initiate appropriate preventative and rehabilitative clinical procedures.
Educate the patient and family in meeting clinical and related needs.
Provide health care instructions to the patient as appropriate per assessment and plan.
Notify the patient’s physician, the Director of Clinical or Designee, and/or Clinical Supervisor immediately of any changes in the patient’s condition.
Receive and conduct physician orders.
Ensure patient’s privacy, home, and medication safety.
Assess the need for and complete Certified Home Health Aide Care plan as needed to meet patient’s activities of daily living needs.
Assess need for therapy/social services and assist scheduler with timely and proper referrals.
Communicate effectively and timely with physician and notify the care team of changes to the patient’s plan of care.
Plan, coordinate, and manage patient care plan for assigned caseload.
Complete OASIS and Clinical Assessment documentation within 48 hours
Develop and complete 485 (Plan of Care) for all assigned patients.
Complete and maintain current: physician orders, clinical communication, and medication profiles for assigned patients.
Conference all team members on assigned patients and complete Case Conference documentation.
Assume responsibility for equipment, medical supply, and resource management for assigned patients.
Function as the direct contact and liaison between patient and physician/home health agency/referral and payer source for assigned patients.
Coordinate with scheduler to ensure adequate and appropriate staffing coverage for all assigned patients.
Take an active role and directly participate in Quality Assurance/Performance Improvement activities.
Implement and ensure self and team compliance with agency policies and procedures, Title 22, Medicare Conditions of Participation, and The Joint Commission standards.
Participate in the performance evaluation of team members as requested by the Director of Clinical or Designee and/or Clinical Supervisor
Assign and schedule work activities.
Review and check work.
Remain flexible to work evenings and/or weekends when necessary.
Participate in on-call rotation.
Participate in community education activities.
Participate in the education and training of new and existing employees as assigned by the Director of Clinical or Designee and/or Clinical Supervisor