RN-Case Manager

Description : Position Summary :

Assesses plans, implements, coordinates, monitors, and evaluates options and services to meet client's health needs through appropriate communications and utilization of available resources to promote quality, cost-effective outcomes. Via assessment of client, the RN will develop and implement a Plan of Care based on utilization guidelines and Clinical Pathways. The focus of service delivery is on providing the right mixes of services and service resources that result in the client achieving the Plan of Care. Good communication skills to facilitate coordination of care. Familiarity with decimals and metric system. Proficient in use of OASIS. Knowledge of OSHA, JCAHO / CHAP, State and Federal standards. Familiar with payor reimbursement guidelines. Knowledge of standard precautions. Must thoroughly understand PPS, be clinically astute, and utilize case management guidelines to promote positive outcomes, utilize automation effectively, and incorporate effective processes and collaboration.

Requirements :

Essential Duties & Responsibilities :

• Performs client admissions, resumption of care, follow-up using OASIS data collection in a timely, legible, accurate manner.
• Responsible for monitoring and managing core measurements pertinent to the department to assure compliance with the operating plan.
• Identifies, documents and reports signs and symptoms of altered health status to physician and Clinical Team Manager. Obtains appropriate orders to increase / decrease visit frequency. Obtains medical orders to alter treatment plan.
• Develops Plan of Care consistent with clinical assessment findings, diagnosis, orders, HHRG Case Mix category, and appropriate utilization guidelines / clinical pathway specific to each client. Sets and evaluates attainable, specific, and measurable goals and outcomes.
• Administers meds and treatment according to Plan of Treatment.
• Teaches nursing care appropriate to client's condition. Teaching based on client / caregiver level of understanding and is properly reflected in records.
• Coordinates care, integrating other health team members. Participates in intra – disciplinary conferences as required.
• Documents client records according to agency policy. Completes clinical notes, Plan of Care and medication records in a timely, legible and accurate manner.
• Notes progress towards discharge planning. Communicates with physician, and appropriate staff regarding discharge planning.
• Completes all discharge summaries according to policy and procedures.
• Supervises the LPN and Home Health Aide to ascertain compliance with Plan of Care.
• Makes supervisory visits in home at least every 14 days and documents visit in the clinical record to ascertain quality of care rendered.
• Utilizes knowledge of nursing, biological, social science, PPS, case management guidelines, and collaborative resources within the agency as well as outside the agency to assist with the development and / or revision to the Plan of Care to promote positive outcomes.
• Participates in back up call according to need of agency.
• Demonstrates safety precautions in compliance with OSHA, JCAHO / CHAP, and Federal and State standards.
• Operates medical equipment correctly for client care.
• Maintains current knowledge of nursing / home care as well as agency's policies and procedures via in-services, testing, skills labs, and on-going CEU's.
• Selects orients and assigns work for direct reports. Develops job design and performance standards, initiates and completes all elements of the Integrated Performance Management process, and makes recommendations for issues related to promotions, disciplinary actions and terminations.
• Updates management regarding potential problems or concerns. Also responsible for consulting with clinicians or managers as needed.
• Maintains an understanding of the company's scope of services.
• Participates in interdisciplinary conferences as required.
• Submits clinical documentation in a timely manner according to agency policy.
• Understands the infrastructure and how and where to transfer calls in the company.
• Maintains a professional image.
• Uses appropriate phone etiquette.
• Promotes a customer friendly atmosphere for all visitors and ensures client confidentiality at all times.
• Participates in accreditation program.
• Performs other duties as assigned.

Licenses, Certifications and / or Registrations :

Working Conditions :

Office / Home Environment. May be exposed to biological hazards.

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