RN (Registered Nurse) Case Manager

Alternate Solutions Health Network•Detroit, MI

About The Position

The Registered Nurse Case Manager (RNCM) is accountable for assessing patient conditions and leading the development and implementation of plans of care. The role provides case management and skilled nursing care, coordinates the disciplines involved in delivering quality, cost-effective, billable care, and supervises care under physician direction. The RN educates patients and family members, promotes patient safety, completes accurate documentation, complies with applicable legal requirements, and practices within the state-defined scope of practice. The position serves patients in their homes across Troy, Royal Oak, Madison Heights, Clawson, and Berkley for Beaumont Home Health. The schedule is Monday through Friday, 8 a.m. to 5 p.m., with on-call duties of two weekend shifts and three weekday shifts per month, plus one winter and one summer holiday on call. Paid holidays are offered.

Requirements

At least one year of experience as an RN in an acute care setting.
Current Registered Nurse license in the state of employment.
Valid driver's license and auto insurance listing the employee as a driver.
Ability to communicate effectively and create positive impressions with patients, families, physicians, and coworkers.
Ability to remain calm, patient, accommodating, compassionate, and caring when working with patients.
Knowledge of nursing best practices.
Ability to make appropriate nursing judgments, identify situations, and determine effective solutions.
Detail-oriented and observant.
Disciplined work ethic with the ability to prioritize and be timely.
Ability to follow directions and work as a team member.

Nice To Haves

Home care experience.

Responsibilities

Oversee the patient's care from the beginning to the end of the episode.
Update physician orders in the patient chart and notify the physician of significant changes in the patient's condition.
Coordinate multidisciplinary care as applicable.
Provide skilled nursing care in the patient's home as ordered by the attending physician.
Observe and monitor patient conditions.
Perform OASIS assessments to develop individualized plans of care and adjust them as patient needs change.
Administer medication as prescribed by the physician.
Help reduce rehospitalizations by front-loading visits for high-risk patients and teaching patients preventive measures and sound decision-making.
Promote continuity of care through appropriate admissions, transfers, and discharges.
Counsel patients and families about disease or injury processes and how to manage them; include them in developing the plan of care and listen to their concerns.
Oversee and supervise patient care provided by nurse aides and LPNs.
Evaluate treatments and the patient's medical condition against the plan of care and determine whether the level of care meets the patient's needs.
Communicate supervisory visit results to LPNs and nurse aides.
Complete clinical documentation in accordance with agency protocol and Medicare/Federal guidelines, including documentation of treatment, assessments, and patient education.
Document subsequent, discharge, evaluation/recertification, and resumption-of-care visits within 24 hours; document start-of-care visits within 24 hours.
Complete and submit required documentation within company deadlines.
Maintain an active RN license and follow the plan of care within the scope of practice for a Registered Nurse.
Communicate schedule changes outside the normal schedule to the scheduler.
Participate in on-call requirements, case conferences, in-service trainings, and mandatory agency meetings.
Drive to patients' primary locations for scheduled visits and attend assigned visit locations daily.
Fulfill RN visits in the assigned geographic area according to patient need and federal and state specifications.
Perform other duties as assigned.