RN Case Manager

Smithfield, Virginia

Overview

Works under the supervision of the Nurse Manager and the Director and is responsible for the assessment, planning, implementing, and evaluating the total nursing care of assigned patients on an intermittent visiting basis. The RN may work in a variety of settings (typically in a home care type setting) and roles within Riverside Health System. The RN utilizes communication, critical thinking, problem solving, and decision making to create a care plan for each patient based on physiological, psychosocial and cultural diversity. Responsible for supervising and delegating non-professional personnel working directly with him / her to ensure optimum patient care. Must demonstrate competence in dealing with age related needs of specific patient populations served in their assigned area. Works under the direction of leadership and a multi-disciplinary team (physical, speech, or occupational therapy; medical social services, and Home Health Aide services) to provide a comprehensive range of services or clinical care associated with and in accordance with standards of excellence established by Riverside Health system and facility goals and strategic plans. Supports the hospice philosophy.

What You Will Do

• Assesses, plans, implements, and evaluates the total nursing care of assigned patients on caseload on an intermittent visiting basis. Develops an initial and ongoing comprehensive assessment of client needs, including the impact of the terminal diagnosis on the patients physical. functional, psychological, and environmental needs and activities of daily living.
• Assesses the patient's risk for pathological grief, cultural and spiritual implications, and verbal / non-verbal communication patterns. Assesses the ability of the caregiver to meet the patient's immediate needs upon admission and throughout care. Determines scope and frequency of services needed based on acuity and patient / family needs.
• Accurately completes all required clinical documentation consistently per RHS standards which includes completing and "locking" patient notes and verbal orders, as well as completing certifications and recertification's after the department's multi-disciplinary team meetings. Required documentation is to be completed no later than the last day of the month in order to provide timely billing. Applies specific criteria for admission and re-certification to hospice care to establish appropriate levels of care and the patient's eligibility.
• Implements / initiates an individualized plan of care and recommends revisions to the plan when necessary. Manages patient's discomfort and provides symptom relief. Provides services and / or treatments requiring specialized nursing skill related to palliative and end-of-life care. Consults with, councils and educates the patient and family in meeting nursing needs, the disease process, self-care techniques, end of life care and the processes for dealing with issues of ethical concerns.
• Uses case management approach and refers patient to other services as needed. Coordinates all patient / family services and prioritization of needs with the members of the interdisciplinary teams. Provides on-going evaluation of patient / family response to care. informs the physician and the IDT of changes in the patients needs, and the patient's plan of care. Initiates appropriate preventive and rehabilitative nursing procedures and provides treatments and procedures that contribute to the physiological and psychosocial outcomes and stability of the patient. Prepares clinical and progress notes that demonstrate progress toward established goal(s). Referral of patients to other services as needed.
• Supervises LPN / LVN's, and Home Health Aides in providing services to the patient according to regulatory guidelines. Provides specialized hospice training to other staff, family members and informal caregivers to ensure adequate care. Participates positively in training and support of all team members, volunteers and students as needed. Delegates and prioritizes tasks appropriately to facilitate quality patient care and ensure patient care needs are met. Recognizes and responds to emergency situations. Evaluates own needs for support and uses identified systems and resources to meet need.

Qualifications

Education

Experience

Licenses and Certifications

To learn more about being a team member with Riverside Health System visit us at https : / / www.riversideonline.com / careers .