***Eligible for $5,000 bonus only if you are an external candidate.
The RN Case Manager uses clinical nursing knowledge, physical assessment, teaching and procedural skills to deliver high quality patient care in the patient’s place of residence. The RN Case Manager develops and oversees the home health plan of care under the direction of the physician and ensure appropriate interdisciplinary involvement to ensure the best outcome for each patient. The RN Case Manager delivers patient care directed by the physician as established in the home health plan of care that is consistent with clinical best practices and results in high quality, improved outcomes and exceptional patient experience.
Essential functions are the duties and responsibilities that are essential to the position (not a task list). o not include if less than 5% of work time is spent on this duty. Be specific without giving explicit instructions on how to perform the task. Do not include duties that are to be performed in the future. Duties should be action oriented and avoid vague or general statements.
Patient Care/Care Coordination
- Makes visits to the homes of patients requiring home health nursing services and assumes responsibility for an ongoing interdisciplinary assessment of the patient.
- Performs initial and comprehensive assessments on all patients in accordance with agency policies and procedures.
- Performs nursing assessment at each visit in accordance with agency policies and procedures.
- Ensures quality and safe delivery of services to patients according to the care plan.
- Uses equipment and supplies safely, effectively, and efficiently.
- Promotes patient independence by teaching patients and family members to understand the following as well as any additional education needs identified by the assessing clinician and/or physician:
- Treatment and disease management
- Medications purpose, use, side effects, potential adverse effects
- Proper use, safety hazards, and infection control issues related to the use and maintenance of any equipment provided
- Patient plan of care
- Emergency preparedness
- Provides the services that are ordered by the physician as indicated in the plan of care.
- Provides patient, caregiver and family counseling and education as indicated in the plan of care.
- Develops and continually updates a plan of care that specifies the care and services required to meet patient-specific needs determined during the comprehensive assessment and includes measureable outcomes that will occur as a result of implementing and coordinating the plan of care.
- Develops and updates patient’s discharge plan on every visit ensuring patient and caregiver education and training is facilitating timely discharge and measureable goals and outcomes are attainable, realistic and up-to-date.
- Includes the patient, representative and caregiver in all plan of care decisions.
- Assesses the need for plan of care updates and every visit and includes the patient and family in care planning decisions and communicates care plan revisions to the patient, representative, caregiver and all physicians issuing orders for the home health plan of care.
- Maintains accurate and timely documentation of clinical records and time/travel entries.
- Receives, relays and documents verbal orders in accordance with state and federal regulations and in a timely manner to prevent adverse patient outcomes.
- Is responsible for obtaining physician orders prior to initiation of care and notifying the physician of any changes in the patient’s condition.
- Communicates with all physicians involved in the plan of care and other health care practitioners related to the current plan of care.
- Identifies patient’s risks for hospitalization and/or emergency department use and proactively intervenes to prevent adverse events.
- Supervises home health aide and licensed practical nurse staff and documents supervision in the patient medical record.
Home Care Performance Criteria
- Delivers quality care and completes clear, concise and accurate clinical documentation of care provision in accordance with home health conditions of participation (CoPs), various payer home health coverage criteria, accreditation standards, professional standards for discipline/credential and the home health plan of care.
- Maintains competence in OASIS data collection and documentation and submits all initial and corrected assessments according to CMS guidance and agency policies and procedures.
- Participates in clinical review of records to monitor quality and accuracy, appropriate utilization, appropriate involvement of interdisciplinary team members, appropriate referrals and coordination of care.
- Participates in peer review and other quality assurance activities, as assigned.
- Uses appropriate infection control procedures and safety measure to protect employees and patients.
- Provides patient and family education using UPaH approved patient teaching materials only.
- Participates in case conferences, in-service programs and other meetings required to ensure coordinated and comprehensive care.
- Reviews all patient assignments prior to scheduling first visit and accepts patient assignments only for which qualified and competent in any specific care/technical skill/procedure needed.
- Participates as a member of the interdisciplinary team.
- Participates in quality assurance/performance improvement (QAPI) activities, as assigned.
- Maintains professional knowledge for discipline/credential/license ensuring inclusion of content specific to home and community based care.
- Communicates professionally, effectively and timely to all team members and co-workers and responds to all communication in a timely manner including, but not limited to e-mails, phone communication and meeting follow-up responsibilities.
- Establishes and maintains positive interpersonal relationships with team members, patients and family members while maintain personal and professional boundaries.
- Assist with new employee orientation when necessary.
- Effectively plans, organizes, sets priorities and completes works assignments with minimum direct supervision per agency policy and within established time frames.
- Maintains productivity standards as defined by home care supervisor.
- Meets or exceeds agency expected outcomes related to patient experience and hospitalization utilization.
- Participates in evening, night and weekend coverage to ensure nursing services are accessible to all patients 24 hours a day, 7 days per week (schedules and rotations determined by region).
- Performs other duties as assigned by home care clinical supervisor and/or administrator.
Basic UPH Performance Criteria
- Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
- Demonstrates ability to meet business needs of department with regular, reliable attendance.
- Employee maintains current licenses and/or certifications required for the position.
- Practices and reflects knowledge of HIPAA, TJC, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
- Completes all annual education and competency requirements within the calendar year.
- Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of administrative staff.
- Takes appropriate action on concerns reported by department staff related to compliance.
- Maintains compliance with Personnel policies and procedures.
- Behaves in a manner consistent with all Corporate Compliance policies and procedures.
Identify items that are minimally required to perform the essential functions of this position.
- Graduate of State Board approved program for Registered Nurses and valid license as RN in state(s) where providing
- One year nursing experience caring for similar patient population as to be assigned.
- Valid licensed driver with automobile insurance in accordance with state(s) and/or organizational requirements.
- Mandatory Reporter: Child & Dependent Adult Abuse.
- Person Centered Care (PCC) course completion within first 12 months of hire and annual completion of competency validation activities.
- CPR: Maintain a valid Basic Life Support (BLS) Healthcare Provider Card with Re-certification.
- Basic knowledge of current, frequently used medications, including modes of administration, actions and side effects.
- Competency in variety of nursing skills and ability to perform without supervision (NPWT, complex wound care, IV therapy, catheter care, ostomy care, chronic disease management assessment and teaching).
- Strong interpersonal skills.
- Ability to work as a collaborative team member.
- Ability to understand and apply guidelines, policies and procedures.
- Ability to navigate and perform basic use of Microsoft Office products.
- Maintains a reliable mode of transportation and has the ability to drive safely during all day and night hours and in all types of inclement weather.
- Use of usual and customary equipment used to perform essential functions of the position.
Preferred or Specialized
Not required to perform the essential functions of the position.
- Home care experience
- 2+ years nursing experience
- ANCC certification in area applicable to home care patient population
- Experience with documentation in an electronic health record.