Home Health Case Manager

Licensure: Must have an active RN license for the state of TexasExperience: . One year of experience in home health care preferred. Management experience preferred.Skills: Nursing skills as defined as generally accepted standards of practice. Excellent interpersonal skills and the ability to communicate effectively. Demonstrates proven decision-making skills. If required to make visits, proof of current CPR certification.

Essential Functions

• Coordinates patient/client care. Coordinates and integrates care provided by Agency staff, including contractual providers
• Ensures communication with all physicians involved in patient's/clients plan of care and other healthcare practitioners
• Integrates orders from all relevant physicians involved into the plan of care and ensures the orders are approved by the responsible physician
• Coordinates referrals
• Participates in activities relevant to professional services including development of qualifications. Recommends resources needed to provide care. Makes patient/client and personnel assignments
• Assures that patient/client needs are continually assessed. Assures reassessment of the patient's client's needs is performed by the appropriate healthcare professional when there is significant health status change in the patient/client's condition, at the physicians request , and after hospital discharge.
• Assures the development, implementation, and updates of the individualized plan of care in partnership with the patient/client, representative (if any) and caregiver(s)
• Ensures provision of services as ordered by the physician as indicated in the plan of care, including patient/client and caregiver education and patient/client, caregiver, and family counseling. Prepared clinical notes as appropriate
• Assumes responsibility for continuity, quality, and safety of services delivered in compliance with state and federal regulations
• Collaborates on development and implementation of policies and procedures which guide and support the provision of care. Collaborates with Agency leadership and appropriate staff to develop the organizational plan as it pertains to patient/client care
• Monitors and participates in the QAPI program and assures appropriate corrective measures are performed
• Promotes compliance with all fiscal intermediary and/or other third-party payors, through education, coaching, and other assistance, as necessary
• Monitors systems and identifiers problems areas to Administrator both verbally and through written reports
• Meets mandatory continuing education requirements of the Agency and licensing board
• Promotes and educates regarding the concepts of the infection control and standard precautions in coordinating or performing patient/client care activities to prevent contamination and transmission of disease
• Uses effective interpersonal relations and communication skills; facilitates the use of the skills by other member to achieve desirable outcomes
• Participates in the Agency sponsored in-service trainings
• Ensures that care offered by the Agency, including any branches, is consistently available to all patients/clients