Registered Nurse Case Manager

Reports to: Clinical Supervisor

Supervises: LPN, CNA

Risk of Exposure to bodily fluids: High

Job Description:

A registered nurse case manager provides intermittent skilled nursing care to pediatric patients, in the place of their residence. The case manager is responsible for the development, implementation and evaluation of individual patient care plans in accordance with physician orders and under direct supervision of the Clinical Supervisor and Director of Nursing services. The case manager is responsible for providing supervision of paraprofessional staff and licensed practical nurses as needed in accordance to Colorado State law. This is a full-time salary position.

Working Environment:

Works indoors, both in the agency office and in-patient homes; travels to and from patient homes. Possible exposure to pet dander and other environmental allergens.

Responsibilities:

• Coordinates total patient care by conducting the initial comprehensive assessment to determine the type and amount of care/services needed for each individual patient.
• Works closely with the patient’s primary caregivers to develop a plan of care to be countersigned by the overseeing physician.
• Encourages open communication with the patient’s primary caregivers to ensure the best possible care is being provided to the patient and any changes in condition are addressed immediately.
• Refers patients appropriately, and under the orders of the signing physician, for paraprofessional, physical therapy, occupational therapy, speech therapy, and/or social worker needs.
• Discusses with the appropriate supervisor the need for the involvement of other members of the health team
• Understands and adheres to established agency policies and procedures at all times.
• Provides services in accordance with the plan of care.
• Demonstrates competent performance of technical skills according to established procedures.
• Furnishes those services requiring substantial, specialized nursing skill.
• Evaluates the effectiveness of homecare services to the patient and family on an ongoing basis. Processes orders and notifies physician of patient needs and changes in condition according to agency’s best practice guidelines.
• Consults with the attending physician concerning changes in patient’s condition, checks with the appropriate supervisor and makes changes to plan of care as appropriate.
• Processes orders, performs admission, transfer, re-certification, resumption of care and discharge paperwork for the patient per agency’s best practice guidelines.
• Submits clinical notes and other clinical record forms outlining the services rendered per agency policy.
• Utilizes OASIS assessment when appropriate.
• Participates in the patients discharge planning process and provides physician with a discharge summary upon completion of home health care services.
• Communicates with all other disciplines or agencies involved in patients care no less often than every 30 days and documents care coordination per agency policy.
• Works together with other case managers to ensure patient needs are adequately covered per physician orders.
• Supervises and evaluates the care given by paraprofessionals as required by state and agency regulations: LPN every 30 days and HHA/CNA every 14 days (or per regulatory requirements)
• Assumes responsibility for the delegation of care per agency policy.
• Participates in teaching/supervision of other clinical personal and caregivers.
• Collaborates with the appropriate department supervisor to develop required written evaluations of the paraprofessionals performance for the patients managed under their individual case load.
• Records supervisory visits conducted with the CNA and LPN.
• Evaluates the effectiveness of nursing service to the individual and family on an ongoing basis.
• Attends weekly case management meetings and continually strives to improve his/her nursing care skills by attending in-service education, formal education, workshops, and conferences.
• Adheres to federal and state guidelines always.
• Adheres to agency standards and consistently interprets and accurately performs all assigned responsibilities.
• Maintains acceptable attendance status per agency policy.
• Demonstrates effective time management skills through daily documentation and infrequent overtime for routine assignments.
• Immediately reports to clinical supervisor or director of nursing any patient incidents/variances or complaints.
• Reports all incomplete work assignments to clinical supervisor and provides a tally of total patients seen at the end of each work day if schedule varies from original scheduled plan.
• Takes on-call duty when assigned and is available to work holidays if necessary.
• Performs admissions in Pueblo and Colorado Springs area.

Qualifications:

• Graduate from an accredited school of nursing with an associate or bachelor’s degree in nursing, and actively licensed in the state of Colorado as a Registered Nurse.
• One (1) year of nursing experience in the home health care setting, experience in pediatric nursing preferred.
• Must have a working knowledge of state and federal home health agency regulations and compliance standards, as well as an understanding of clinical management as it pertains to the case management role.
• Must have knowledge of the competencies related to the nursing profession, including but not limited to effective documentation, utilization of ICD-9 and ICD-10 diagnoses/codes and OASIS.
• Current CPR certification from an American Heart approved course.
• Valid driver’s license, reliable transportation, and active auto insurance.
• Must be to access consumers' homes which may not be routinely wheelchair accessible. Hearing, eyesight and physical dexterity must be sufficient to perform a physical assessment of the patient condition and provide patient care.
• All employees are subject to a Background check prior to be selected for employment.