RN - Complete Care Program - Home Health Case Manager

Presbyterian Healthcare Services•Pueblo, CO

3d•$38 - $51

About The Position

Deliver hospital-level care where it matters most—at home How you grow, learn and thrive matters here. • Educational and career development options, including tuition and certification reimbursement, scholarship opportunities • Staff Safety (a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern) • Differentials for night/weekend shifts, higher education, certifications and various lead roles (for eligible positions) • Malpractice liability insurance • Loan forgiveness through the New Mexico Higher Education Department • EPIC electronic charting system In this role with our Hospital at Home Department, you will be responsible for case management of Home Healthcare patients. Ensures that care delivery is within quality and utilization guidelines and is directed toward the achievement of desired clinical outcomes for the disease state. Responsible for development, coordination and scheduling delivery of care through a multidisciplinary team to the patient in the home or community setting. The Case Manager assures completeness, timeliness and appropriateness of the patient care plan, its implementation and ongoing evaluation. Assures communication with the multidisciplinary team, support services and community resources to ensure that care goals are achieved in the most efficient and cost effective manner possible. Ensures that documentation is timely, accurate, complete and reimbursable. Is a patient advocate. Precepts newly hired nurses. PRN staff will not be responsible for managing a caseload; but all staff are required to manage the case load, follow up and communication for their daily assignments

Requirements

Associate Degree in Nursing
State of New Mexico or Compact State Nursing License
BLS certification REQUIRED at time of hire
Minimum one-year acute care experience within the last 3 years REQUIRED
Current Drivers License and Auto Insurance

Nice To Haves

Hospice or home care HIGHLY experience preferred

Responsibilities

Demonstrates nursing care management of patients as evidence by a. Assessments that are complete, timely, and appropriate of physical, mental, psychological/social (behavioral), functional, financial, treatment, resource and spiritual needs of patients.
Analysis that defines problems that are capable of correction through home healthcare and hospice interventions and are prioritized in development of care plan.
Intervenes consistently with orders and changes interventions with orders to meet changes in patient need
Evaluates each visit the effectiveness of interventions and the patients response to intervention.
Provide direct patient care by assessing patient for care needs, resources to meet needs and developing a home care or hospice plan of care in conjunction with physician.
Assures completion of required OASIS assessments according to regulations for home care and QAPI measures for hospice .
Coordinates implementation of the plan of care through a multidisciplinary home care or hospice team, community resources and the physician
Ensures plan of care is followed and that documentation complies with regulation.
Maintains a department productivity standard for visits and caseload management.
Demonstrates professional accountability for self-scheduling patient case load with appropriate frequency and duration, and concurrently updates schedule throughout the day as needed so that ongoing patient needs can be met.
Assure patients on case load are notified timely of their visits and of any unplanned schedule changes accommodating, when possible, patent preferences for time of day.
Precepts newly hired nurses, and students and serves as a resource person and professional role model as needed.
Maintain communication with the multidisciplinary team s and assures that orders for necessary care plan changes are obtained and assures that changes are communicated timely to the team.
Initiates documentation in the home and completely records all care delivery so that receiving staff have record of care delivered by the end of each day which includes admissions.
Demonstrates proficiency and competency in interventions (treatments) required through day to day practice and annual competency testing.
Delegate or assign aspects of patient care to health care team members commensurate with their validated competency to perform the task.
Be professionally responsible for current nursing research, current nursing standards, home care or hospice philosophy in order to maintain quality.
Be responsible for clinical supervision of licensed and non-licensed assistive personnel.
Participates in agency continuous quality improvement activities as required.
Assume other leadership roles as required by the department.
Responsible for weekend and holiday coverage and evening call for agency and patient home visits as required on a rotating basis.
Assure clinical outcomes are met and sustained .
Performs other functions as required.

Benefits

Educational and career development options, including tuition and certification reimbursement, scholarship opportunities
Staff Safety (a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern)
Differentials for night/weekend shifts, higher education, certifications and various lead roles (for eligible positions)
Malpractice liability insurance
Loan forgiveness through the New Mexico Higher Education Department
EPIC electronic charting system
Sign on and relocation assistance available to qualified Candidates!
Presbyterian employees have access to a fun, engaging and unique wellness program, including free on-site and community-based gyms, nutrition coaching and classes, mindfulness and meditation resources, wellness challenges and more.

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