Field Registered Nurse

The RN (Registered Nurse) Case Manager is responsible for providing Rebekah Certified Home Health Agency patients with quality care in a safe and judicious manner. The Case Manager will assist in facilitating and coordinating all services that the Home Health Agency patients require. He or she will be responsible for promoting quality, patient access care, cost-effectiveness within a well integrated healthcare delivery system. In addition the nurse will be responsible for the on-going assessment, treatment and evaluation of the patient’s condition and family situation, as well as the supervision and evaluation of aide personnel that are assigned to provide services to the Home Health Agency patients.

QUALIFICATIONS :

• Currently licensed as a Registered Professional Nurse in New York State
• Has recent community health care / acute care / long term care experience
• Minimum 2 years experience as a Registered Professional Nurse : -medical / surgical / emergency room
• Two to four years of home care experience preferred with strong clinical skills
• Has knowledge of Medicare and Medicaid regulations
• A valid NYS driver’s license, own and have the use of a automobile vehicle to conduct home visits preferred
• Physically and mentally capable of performing job responsibilities
• Strong interpersonal skills
• General knowledge of computers
• Good organizational skills
• Good interpersonal, problem solving and communication skills
• Strong clinical skills
• Ability to drive own transportation to and from assigned patients, or knowledge of Public Transportation in serviced counties
• Ability to manage assigned case load, conduct 6-8 visit points during designated field days, including initial / admission visits
• Ability to conduct patient admission and reassessment
• Demonstrates competency with OASIS tools
• Able to lead, and manage interdisciplinary team
• Strong verbal and presentation skills

RESPONSIBILITIES :

Nurses Bag Supplies & Equipment :   Responsibility & Maintenance

Home Visit :   Focus : -Holistic / comprehensive-head-toe, medication / treatment / supplies, PERS, diet / food, weather precautions / rehab services, DME, social work, nutrition / environmental, safety, caregiver support, finance, visit frequency and aide service and supervision. +OTHER

Initial / Admissions :   Conducts Initial / Admission visits as assigned. Assess and validated the need for HHA. Completes all pre admission and or admission documentation. Communicate with the appropriate Primary Care Physician and completes the Plan Of Care.

Aide Competency :   Frequency may be greater than the mandatory : Initial, new tasks, and annual

Paraprofessional Supervision :   Frequency may be greater than the mandatory and new tasks : Initial and ongoing : HHA : Initial and Q2W. PCA : initial and QM Homemaker & Housekeeper : initial and QM

Patient / Caregiver and aide :   Education / teaching / assessment / monitoring / supervision. Return demonstration / intervention.

Visit Schedule / Calendar :   Prepare Monthly Visit Calendar at least 5days before the beginning of each month to reflect the assigned case load and needed changes daily.

Routine Home Visits :   Conduct 5-6 routine home visits and documentation daily.

60 Day Reports :   Conducts 60 Day assessment for evaluation of treatment methodologies, outcomes and discharge planning, as well as the plan for the next 60 days, in addition to the required Plan Of Care. A summary of this report and the original Plan Of Care is submitted to the patient’s physician; original and a copy of the POC is submitted to the HHA for inclusion in the patients record within 3 (three) business days of the due date.

Conditional Change : SIC-Decline / Improvement :   Requires immediate / prompt notification to MD verbal and written (487) and visit / progress note documentation.

New / Changes in Medications :   Require 487, Medication Record, Visit Report, progress note, diagnosis for use

Discharge Summary :   Completes and submits discharge summaries reports at the completion of services that includes treatment methodologies, service outcomes and any recommendations for follow-up care to the patient’s physician and to the HHA.