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:

• Patient safety assessment in the home
• Lead and collaborate with assigned patient care team
• Oversees the total care and safety of assigned patients.
• Performs admission/readmission/discharge functions
• Ensures proper documentation is completed by entire care team
• Conducts field visits and supervisory visits for LPN and HHA
• Collaborates with assigned care team to develop patient care plans, including PRN visits in a timely manner
• Monitors services provided to ensure POC is followed as written
• Assists with retrieving verbal orders and following up with Physicians
• Timely submission of written POC to physicians.
• Participates in Agency QAPI Program
• Informs the Assistant Director of Patient Services about daily PRN visits for assigned case load
• Participates in 24 hour on call service as per Home Health Agency Policy
• Participates and develops emergency and disaster preparedness for assigned case load
• Provides initial assessment within 24-hour of referral (including OASIS) or as soon as possible if patient is unavailable while documenting best efforts
• Provides comprehensive assessments and evaluations of patient's physical and mental status, utilizing nursing principles and guidelines, professional knowledge and interviewing skills to ensure and provide quality patient care
• Timely development and implementation of Home Health Aide Plan of Care in collaboration with patient/caregivers; provides patient/caregiver and healthcare worker orientation, monitors and supervises
• Provide timely changes/revision to the Aide Plan of Care
• Timely communication of referrals to interdisciplinary team members
• Timely completion and submission of OASIS and related POC
• Provides patient/caregivers/healthcare worker with teaching/education on an on-going basis; Assesses knowledge level and need for further interventions
• Provides skilled nursing services according to medical orders and Agency's policies and procedures
• Supervise, instruct and evaluate assigned healthcare workers
• Communicates with Assistant/Director of Patient Services to discuss patient eligibility
• Supervises all involved disciplines in the plan of treatment
• Reviews reports from all involved disciplines, re-evaluating needs and plans as indicated
• Reassesses patient's needs for services on a continual basis and discusses any changes in the plan of treatment with patient/authorized practitioner/family
• Prepares written documentation and summaries of the patient's progress as needed for continuation of healthcare worker services, i.e. OASIS and interim visit reports with the HHA policies and procedures
• Coordinate care delivery, develops implements, assess and monitor delivery of care
• Timely communication and documentation with members of the interdisciplinary team
• Plans, facilitates and documents patient's discharge from the Home Health Agency and discipline
• Conducts ongoing patient needs assessment and makes necessary and timely interdisciplinary referrals and changes to the Aide Plan of Care
• Participates in interdisciplinary case conferences to ensure coordination and continuity of patient care
• Becomes familiar with all resources necessary to provide a complete/comprehensive patient care, e.g. rehabilitation, respiratory and nutrition therapies, medical social work and DME
• Documents and submits timely, accurately and complete required documentation to meet regulatory and agency requirements
• Documents accurate and complete information in the patient's clinical record
• Assumes responsibility for continued professional growth by maintaining professional memberships, and updated professional knowledge and participation in patient education programs to ensure optimum quality of patient care
• Initiates and maintains verbal/written communication according to the HHA policy to ensure coordinated patient quality care
• 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.
• Performs other nursing activities as assigned.