RN Home Health Case Manager - Fulltime or PRN ($7000 hire-on bonus for FT)

Johnson County Hospital•Tecumseh, NE

12d•Onsite

About The Position

Performs duties under general medical/nursing supervision and direction of the patient's provider and Home Health Director. Performs Case Management duties as well as the development of the 485 Plan of Care, home visits for the purpose of providing Home Health services according to the written Plan of Care assigned to his/her care and is regulatorily required by CMS. Partners and participates with the Home Health Director, LPN's, Physical, Occupational and Speech Therapists, HHA in the on-going review and facilitation of the Care Plan, Patient treatments including request of interventions, goals, family/caregivers and plans for discharge or transfer of care. Responsible to maintain and facilitate compliance and regulatory process as identified by CMS and JCHH.

Requirements

Licensure as a Professional Registered Nurse in the State of Nebraska, completes necessary CEU's and maintains an unencumbered license.
Employed by the Johnson County Home Health (JCHH) a service provided to the area and surrounding communities by the Johnson County Hospital (JCH).
BLS Certification.
1-2 years recent nursing experience.
3 + years customer service experience, preferably in human services and possess/demonstrates a commitment to customer service.
Maintains a private vehicle and has insurance coverage for his/her own vehicle, allowing for self-transportation for making home visits.
Compassion, patience, kindness, empathy and creating a safe effective work and care environment.
Health promotion and maintenance.
Medical knowledge and understanding of pathophysiology.
Nursing skills, nursing process.
Observational skills.
Critical thinking skills.
Knowledge of infection control practices.
Ability to analyze information.
Research skills.
Strong decision-making skills.
Excellent people sills and able to relate to all cultures, behaviors individuals or different educational backgrounds.
Have strong conflict resolution skills.
Verbal and written communication skills.
Strong leadership and management skills.
Integrity.

Nice To Haves

Professional or personal experience supporting individuals with disabilities, mental illnesses, or challenging behaviors highly preferred.

Responsibilities

Liaison between patient, family/caregiver, Home Health Director and physicians.
Assists with weekend patient care coverage as designated by the Director of Home Health.
Admits new patients by reviewing records, co-morbidities and past history, conducting the Admission Assessment interview and physical assessment (Medicare Walk); determining the need for therapeutic medical intervention, psycho-social and psychiatric evaluations, reviewing therapist evaluations, treatment objectives and plans to develop a comprehensive 485 Plan of Care.
Provides routine care for patients including head to toe assessments, vitals and mental health evaluations as prescribed by the provider.
Establishes treatment interventions including setting schedules and routines; coordinating services being provided, arranging resources, including transportation if needed.
Intervention for any patient with change in condition, including physician notification, orders and team notification same day.
Monitoring patient progress, communicates that progress or need of changes when leading Case Conference reporting and or scheduling Patient Care conferences as needed for assigned case load.
Maintains patients records with accurate and timely completion of all required documentation for his/her patient census.
Regularly reviews Home Health team's routine notes; communicating concerns or needed updates as identified by the review.
Works toward timely discharge of patients and facilitating discharge plans with prudent utilization of resources by the team; orienting and training family members/caregivers and providing outside resources as needed.
Participates in Agency Chart auditing as directed.
Improves staff competence by providing educational resources; balancing work requirements with learning opportunities, evaluating the application of learning to changes in treatment results.
Partners with Home Health director to improve treatment results by studying, evaluating and re-designing processes; implementing changes; in patient care process.
Provides health education to not only patients, caregivers, but the community at large.
Meets budget by ensuring appropriate diagnoses when creating the Plan of Care, monitoring expenses of supplies, by considering utilization of visits at time of admission, the preparation and needs for safe discharges; assisting with implementing cost-saving actions when identified.
Work with Home Health Director to aid in ongoing updates of patient status and progress towards goals.
Assists Physicians and Registered Nurses with care and treatments ordered.
Communicates interventions and goals with patients and their family members or caregivers as prescribed by the Plan of Care.
Administers oral and injectable medications if needed or ordered, monitors for refills, reconciles medications with each and every visit. Reporting any inconsistencies or changes to the provider same day.
Preforms standard diagnostic procedures including phlebotomy/venipuncture or other lab requests able to be completed in the home.
Provides wound care and skin management.
Monitors, changes provide cares for catheters or appliances including PICC line cares and dressing changes, LVAD care/dressing changes, Pleur-evac, Ostomy, ileostomy, Foley, Suprapubic, IV Infusions and other skilled treatments as ordered by the provider.
Is capable of interpreting guidelines to determine the payment mode of the patient.
Works with the Home Health Director to aid in continued updates of quality of care.
Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.
Enhances department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
Has knowledge of the state laws governing the scope of nursing practice.
Works with area hospitals, nursing homes and physicians regarding discharge planning as needed.
Keeps current in all changes to OASIS and Coding guidelines.
Performs any other duties as deemed necessary by the Home Health Director.