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RN Case Manager uses clinical nursing knowledge, physical assessment, teaching and procedural skills to deliver high quality patient care in the patient’s place of residence. The RN Case Manager develops and oversees the home health plan of care under the direction of the physician and ensure appropriate interdisciplinary involvement to ensure the best outcome for each patient. The RN Case Manager delivers patient care directed by the physician as established in the home health plan of care that is consistent with clinical best practices and results in high quality, improved outcomes and exceptional patient experience.

Essential Functions/Responsibility

Patient Care/Care Coordination

• Makes visits to the homes of patients requiring home health nursing services and assumes responsibility for an ongoing interdisciplinary assessment of the patient.
• Performs initial and comprehensive assessments on all patients in accordance with agency policies and procedures.
• Performs nursing assessment at each visit in accordance with agency policies and procedures.
• Ensures quality and safe delivery of services to patients according to the care plan.
• Uses equipment and supplies safely, effectively, and efficiently.
• Promotes patient independence by teaching patients and family members to understand the following as well as any additional education needs identified by the assessing clinician and/or physician:  Treatment and disease management; Medications purpose, use, side effects, potential adverse effects; Proper use, safety hazards, and infection control issues related to the use and maintenance of equipment provided; Patient plan of care; Emergency preparedness; 
• Provides the services that are ordered by the physician as indicated in the plan of care.
• Provides patient, caregiver and family counseling and education as indicated in the plan of care.
• Develops and continually updates a plan of care that specifies the care and services required to meet patient-specific needs determined during the comprehensive assessment and includes measurable outcomes that will occur as a result of implementing and coordinating the plan of care.

SUBMISSION REQUIREMENTS

• 1 Year of Home Care experience required
• Competency in variety of nursing skills and ability to perform without supervision (NPWT, complex wound care, IV therapy, catheter care, ostomy care, chronic disease management assessment and teaching) – Preferred
• EMR Experience (EPIC) – Preferred
• COS-C Certification – Preferred
• Mandatory Reporter: Child & Dependent Adult Abuse.  Person Centered Care (PCC) course completion required before start

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